Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total hip replacement surgery and inpatient stay while out 
of the country provided from June 17, 2021, to June 20, 2021. 
 
You asked the Plan to pay for the total hip replacement surgery and inpatient stay while out of the country. You 
say that the total hip replacement surgery and inpatient stay were medically necessary to receive while out of 
the country. The Plan denied your request. The Plan says the total hip replacement surgery and inpatient stay 
were neither emergent nor urgent to be provided out of the country. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 pay for the total hip replacement surgery and 
inpatient stay while out of the country. Our reviewer says that the total hip replacement surgery and inpatient 
stay were neither emergent nor urgent to be provided out of the country. Our physician reviewer found 
osteoarthritis is not a condition that has a sudden onset. It is characterized by pathologic changes in cartilage, 
bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional 
limitation. Therefore, the enrollee could have foreseen requiring the services prior to leaving his service area. 
This enrollee was being treated for right hip osteoarthritis. He underwent a total hip replacement of the right 
hip joint on June 18, 2021, due to severe osteoarthritis of the right hip joint. He had severe pain, limping, and 
difficulty in performing the daily activities.  
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there were no imaging studies provided 
to corroborate severe hip osteoarthritis. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, it would have 
been reasonable to delay the services until the enrollee returned to his service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total hip replacement surgery and inpatient stay while out of the country 
have not been met. Therefore, we decided that the Plan does not have to pay for the total hip replacement 
surgery and inpatient stay while out of the country provided from June 17, 2021, to June 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on October 23, 2020. 
 
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says per the Evidence of 
Coverage, eyeglasses are only covered after cataract surgery. You have no claims for cataract surgery on file. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear.  
 
 
 
 
 
 
  
The services you asked the Plan to pay for are considered routine eyewear. Therefore, we decided that the Plan 
does not have to pay for eyeglasses provided on October 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that an exception should be made since the 
enrollee was in an accident. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until December 8, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says there is no indication that you are insulin-treated with multiple (3 or 
more) daily administrations of insulin or a continuous subcutaneous insulin infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) 
system & supplies. 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says you are not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitoring (CGM) system & supplies.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 18, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve negative pressure wound therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that wound care is not covered for any method used to promote wound healing that is 
unproven by valid scientific literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in this case. The plan has not 
provided the records they used in their denial for this case. The plan clearly used clinical records to come to 
their decision, and they needed to have provided these records to us. Therefore, we decided that the Plan has to 
pre-approve negative pressure wound therapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prodigy Glucometer, test strips, and control solution, and 
Sterilance Twist top lancets with the Sterilance lancing device. 
 
You asked the Plan to pay for the Prodigy Glucometer, test strips, and control solution, and Sterilance Twist 
top lancets with the Sterilance lancing device. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the member must use Plan preferred diabetic supplies. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 pay for the Prodigy Glucometer, test strips, and 
control solution, and Sterilance Twist top lancets with the Sterilance lancing device. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is insufficient data provided to indicate 
why the member needs the requested items over the Plan's preferred items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Prodigy Glucometer, test strips, and control solution, and Sterilance Twist 
top lancets with the Sterilance lancing device have not been met. Therefore, we decided that the Plan does not 
have to pay for the Prodigy Glucometer, test strips, and control solution, and Sterilance Twist top lancets with 
the Sterilance lancing device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like to appeal the denial of 
service and have the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an 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 the laboratory services provided on September 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy services (97110) 
rendered on February 24, 2021. 
 
You asked the Plan to waive the coinsurance for physical therapy services. You say that you were unaware that 
your insurance would not cover this treatment, and you were not informed about any of this. You also say that 
your primary care physician directed you to go to this provider, and they did not inform you of any financial 
responsibility. The Plan denied your request. The Plan says you were 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 20% 
coinsurance for each Medicare-covered service for outpatient rehabilitation services.  
 
You have been asked to pay $13 in coinsurance, which is 20% of the allowed amount for physical therapy 
services ($65 allowed amount x 20% coinsurance = $13). Physical therapy services fall within the outpatient 
rehabilitation 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 coinsurance for physical 
therapy services (97110) rendered on February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy (PT) services (97110) 
provided on February 19, 2021. 
 
You asked the Plan to waive the coinsurance for the PT services. You say that the services should be covered. 
The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Outpatient rehabilitation services.  
 
You have been asked to pay a 20% coinsurance for the PT services (allowed is $65 x 20% = $13). PT services 
falls within the Outpatient rehabilitation 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 
coinsurance for physical therapy (PT) services (97110) provided on February 19, 2021.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN services. You say that the enrollee's oral intake is incapable of 
meeting one hundred percent of her nutritional needs while balancing the protein losses due to hemodialysis. 
You say that treatments such as nasogastric or gastrostomy feedings would be impractical for this enrollee due 
to the severity of her conditions. You say that a non-invasive therapy to treat the enrollee's malnutrition is 
preferred. You say that IDPN is medically necessary for the enrollee. The Plan denied your request. The Plan 
says that the records do not demonstrate that the enrollee is unable to take any food by mouth because of a 
serious medical problem. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes. The rules say that parenteral nutrition is covered when 
medically reasonable and necessary for certain clinical indications.  
 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 IDPN services. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found that the enrollee has end stage renal 
disease (ESRD) and has been on IDPN. Despite counseling and supplementation, the enrollee was unable to 
have adequate nutrition. The enrollee was started on IDPN and it has been interrupted. Our physician reviewer 
found that this IDPN intervention is medically necessary and has been adequate with counseling and oral 
supplements.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have been met. Therefore, we decided that the Plan has to pre-approve 
intradialytic parenteral nutrition (IDPN).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like for this claim to be 
reprocessed and paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from an in-network provider or an 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 the laboratory services provided on September 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening provided on 
August 31, 2021. 
 
You asked the Plan to pay for the screening test. You say that this service was at the request of your physician 
due to your health condition. The Plan denied your request. The Plan says the screening test is a one-time 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening test have not been met. Specifically, the file shows that the Plan paid for an 
abdominal aortic aneurysm screening that you received on November 14, 2019. Therefore, we decided that the 
Plan does not have to pay for the abdominal aortic aneurysm screening provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Office Visit on November 8, 2021. 
 
You asked the Plan to waive the copayment for an Office Visit. You say that you were told the copayment 
would be $25. The Plan denied your request. The Plan says the copayment you are being 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 $50 
copayment for Office Visit.  
 
You have been asked to pay a $50 copayment for Office Visit. An Office Visit falls 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 an Office Visit on November 8, 2021.  
 
Your complaint about being told that the provider was In-Network 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the intermittent urinary catheter (A4352) provided on July 28, 2021. 
 
You asked the Plan to pay for the intermittent urinary catheter. You say that you would like reconsideration 
because this equipment is payable under the Durable Medical Equipment (DME) fee schedule. The Plan denied 
your request. The Plan says that per the Physician Fee Schedule, CPT code A4352 has a status indicator of P 
and is always bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code A4352 is supported in the record. Specifically, per the DME fee schedule, equipment 
billed with CPT code A4352 is separately payable. It is not appropriate to apply the Physician Fee Schedule 
indicators to equipment supplied by DME suppliers. Based on this information, we decided that Medicare rules 
for coverage of the intermittent urinary catheter have been met. Therefore, we decided that the Plan has to pay 
for the intermittent urinary catheter (A4352) provided on July 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.