Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the item is necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
MyoPro powered arm brace at issue in this case meets Medicare criteria for medically reasonable and 
necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Desonide cream. 
 
You asked the Plan to pre-approve Desonide cream. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Desonide cream is not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Desonide cream.  
 Benefits for Desonide cream may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided by a network facility on October 13, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were told there would be no 
copayment for the MRI. The Plan denied your request. The Plan says you have been asked to pay the correct 
cost-sharing amount. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment per visit for the listed Medicare-covered services performed in outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for the MRI. The MRI falls within the Outpatient hospital 
services benefit category. The record shows you received the MRI at an outpatient hospital. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a magnetic resonance imaging (MRI) provided by a network facility 
on October 13, 2021. 
  
Your complaint about miscommunication is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of subcutaneous tissue (11042) and an 
outpatient clinic visit (G0463) provided on July 9 to July 30, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a debridement of subcutaneous tissue and an outpatient clinic visit. You say that 
the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says 
rules for payment for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a debridement of subcutaneous tissue (11042) and 
an outpatient clinic visit (G0463) provided on July 9 to July 30, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided on March 27, 2021. 
 
You asked the Plan to pay for ultrasounds. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation does not support the codes billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76856 is ultrasound, pelvis (nonobstetric), real-time with 
image documentation, complete. The CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal, 
real-time with image documentation, complete. The CPT Code Manual definition of code 93976 is duplex scan 
of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; 
limited study.   
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for ultrasounds. Our reviewer says that these codes do not meet 
the criteria for payment. Our reviewer found the procedure report does not include sufficient documentation to 
confirm a complete male pelvic ultrasound to include bladder, prostate gland, and seminal vesicles was 
performed. The radiology report supports bladder and prostate only. Therefore, code 76856 is not supported. 
The procedure report does not confirm "real time with image documentation" and therefore code 76770 cannot 
be verified. Code 93976 cannot be reported separately from a real-time retroperitoneal ultrasound, so since 
76770 cannot be verified as real time this procedure code cannot be supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasounds have not been met. Therefore, we decided that the Plan does not 
have to pay for ultrasound services provided on March 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need to keep your foot working and keep 
your balance, especially with your age. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on November 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan.. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on November 9, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx: Targeted genomic sequence analysis 
(0037U) provided November 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee meets all of the requirements 
for coverage. The Plan denied your request. The Plan says the records do not meet Medicare NCD/LCD 
criteria. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0037U is FoundationOne CDx: Targeted genomic 
sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene 
copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the ordering provider cannot 
be verified. The records show that the Plan contracted the provider's office and confirmed that the ordering 
provider did not write the order. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne CDx: Targeted genomic sequence analysis (0037U) provided November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (82310, 82728, 83540, 83550, 83970, 
84100) provided on August 11, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory testing (82310, 82728, 83540, 83550, 83970, 84100) provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these are getting to be too expensive to 
keep purchasing supplies. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry specialist office visit provided 
on September 13, 2021. 
 
You asked the Plan to waive the copayment for a podiatry specialist office visit. You say that this was a routine 
visit to cut your toenails. You also say that you have been having this procedure for years and there has been no 
charge. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
The Plan also says that no cost sharing was applied for toenail debridement. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for an in-network podiatry specialist office visit.  
 
 The record shows you had a specialist office visit with your podiatrist on September 13, 2021. The record also 
shows the claim was processed correctly and no cost sharing was applied to the toenail debridement. You have 
been asked to pay a $45 copayment for a podiatry specialist office visit. A podiatry specialist office visit falls 
within the Podiatry Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a podiatry 
specialist office visit provided on September 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychologist visit to be provided by an out-of-network 
(OON) provider. 
 You asked the Plan to pre-approve a psychologist visit. You say that you would like to continue seeing your 
same psychologist. The Plan denied your request. The Plan says based on the rules and rationale, denial is 
being upheld. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a psychologist visit. Our reviewer says 
that you do not meet the criteria for continuity of care with an out-of-network provider. Our physician reviewer 
found that your condition is not considered urgent/emergent condition. You have been seeing this provider 
since 2018. The Plan is able to provide a psychotherapist for treatment of your condition. Utilization of an in-
network provider assures a credentialed and clinically maintained individual assured by the Plan to meet the 
standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a psychologist visit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a psychologist visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayments for gelsyn-3 injections 
provided from October 7, 2021, to October 21, 2021. We also decided that the Plan does not have to waive the 
copayment for a specialist office visit provided on October 21, 2021. 
 
You asked the Plan to waive the coinsurance and copayments for the injections and specialist office visit. The 
Plan denied your request. The Plan says the correct coinsurance and copayments were applied. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Part B drug. Additionally, for the drug administration, you will pay the cost sharing that 
applies to the specialist provider. 
 
Your contract with the Plan also clearly says that you must pay a $45 copayment for services obtained from a 
specialist. 
 
You have been asked to pay $142.46 for each injection, which is 20% of the allowed amount ($712.32 allowed 
amount x 20% coinsurance = $142.46). The injections fall within the Medicare Part B Prescription Drugs 
benefit category. You have also been asked to pay a $45 copayment for each injection administration, as well 
as the specialist office visit. The administration and office visit fall within the Physician/Practitioner Services, 
Including Doctors Office Visits benefit category. The total for all visits is $607.38. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance and copayments for gelsyn-3 injections provided from October 7, 2021, to October 
21, 2021. We also decided that the Plan does not have to waive the copayment for a specialist office visit 
provided on October 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you had a mammogram done on 
November 2, 2021, and November 3, 2021. You say that you should not be charged both copayments. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialty physician diagnostic tests.  
 
The file shows that the Plan has reprocessed the claim for the mammogram received on November 2, 2021, to 
reflect no copayment. The mammogram provided on November 3, 2021, was considered diagnostic due to abnormal findings. Therefore, you have been asked to pay a $30 copayment for the mammogram. The 
mammogram falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
4, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you just went into the 
office to pick up medication. The Plan denied your request. The Plan says the copayment amount charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist office visit provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 11, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to get the 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on November 11, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on November 5, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on November 5, 2021.