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

 
We decided that the Plan does not have to pay for the compression garments coded as A6501, A6532 and 
A6530 purchased April 20, 2022, to May 15, 2022. 
 
You asked the Plan to pay for the compression garments. You say that your physical therapist recommended 
compression sleeves which you had purchased. At no time was you advised that the sleeves were covered. You 
already purchased and feel that the Plan should pay the allowable. The Plan denied your request. The Plan says 
the services were rendered by providers who are not in network and who are not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the compression garments coded as 
A6501, A6532 and A6530 purchased April 20, 2022, to May 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telephone evaluation and management 
service provided on May 12, 2022. 
 
You asked the Plan to waive the copayment for the telephone evaluation and management service. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $5 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $5 copayment for the telephone evaluation and management service. This 
service falls within the physician/practitioner services, including doctor's 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 a telephone evaluation and management service provided on 
May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator (E1390). You say that the requested oxygen 
concentrator (E1390) is medically necessary. The Plan denied your request. The Plan says that the enrollee 
does not meet criteria for the requested oxygen concentrator (E1390). 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 an oxygen concentrator (E1390) Our 
reviewer says that the requested oxygen concentrator (E1390) is medically necessary. Our physician reviewer 
found continuation of the home stationary oxygen concentrator is considered reasonable and medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD) and has been on supplementary 
oxygen at night and with activity, as documented in the medical record. The most recent encounter of 
September 28, 2022, also notes that SpO2 decreased to 88% with activity and corrects with O2 2 Liters Per 
Minute (LPM). This meets Medicare criteria for continued need for supplemental oxygen.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator (E1390) have been met. Therefore, we decided that the 
Plan has to pre-approve an oxygen concentrator (E1390).  
 
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 validity testing billed with code 83789 for date(s) of service 
January 31, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient office visit and an 
electrocardiogram (ECG) provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for an outpatient office visit and an ECG. You say that you believe 
that you should only be responsible for the $40 copayment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 $95 
copayment for in-network Medicare-covered diagnostic procedures and tests performed by a provider other 
than your primary care physician. 
 
You have been asked to pay a $78.24 copayment for an outpatient office visit and a $16.76 for an ECG. The 
total amount you are being asked to pay is $95 ($78.24 + $16.76= $95). This item/service falls within the in-
network Medicare-covered diagnostic procedures and tests performed by a provider other than your primary care physician. 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 outpatient office visit and an 
electrocardiogram (ECG) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) received on June 3, 2022. 
 
You asked the Plan to pay for polycarbonate lenses. You say that the item is necessary, and you want the Plan 
to pay for it. The Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Enhanced lenses are not a covered benefit. Based on this information, 
we decided that the Plan's rules for coverage of polycarbonate lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for polycarbonate lenses (V2784) received on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial. You also 
say the enrollee is not dependent on an insulin pump, but she injects insulin up to three times a day and 
monitoring is the same. The requested CGM is important for the health of the enrollee. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested CGM. 
 
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 and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0554).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 14, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 11, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on June 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) natriuretic peptide 
(83880) complete blood count (85025) and troponin, quantitative (88484) provided April 9, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the claim must be submitted to the primary 
carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has that the 
enrollee has a primary insurance. As the secondary insurer, the Plan cannot be held responsible for the 
emergency visit until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the emergency department visit (99284) natriuretic peptide (83880) complete 
blood count (85025) and troponin, quantitative (88484) provided April 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic socks (E1399). 
 
You asked the Plan to pre-approve the orthopedic socks. You say that the socks are medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve orthopedic socks (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667x2). 
 
You asked the Plan to pre-approve a pneumatic compression device and pneumatic appliances. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says you do not meet criteria 
for approval of the requested items. The clinical information submitted does not show that you failed a 
reasonable trial of a basic pump prior to requesting the advanced pump. The notes do not show that you had at 
least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person 
fitting, training and supervision by a technician who is skilled in and who successfully uses the pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardiac loop recorder for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any stroke, syncope, or any normal short-term heart monitoring. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram monitoring. A recent randomized clinical trial found that continuous monitoring for atrial 
fibrillation with an implanted loop recorder (ILR) (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patient's clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable cardiac loop recorder for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on May 9, 2022. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like this claim reprocessed and 
approved for payment based on the services rendered. The Plan denied your request. The Plan says these 
services are explicitly excluded when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic activities (97530) provided on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided by a chiropractor from 
February 14, 2022, to May 16, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you were told that the copayment would be 
$20 total and are very disappointed that you are not getting much financial help for the acupuncture. The Plan 
denied your request. The Plan says these acupuncture services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for acupuncture services provided by a chiropractor from February 14, 2022, to 
May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97810) acupuncture, 
each additional 15 minutes (97811) and infrared light therapy (97026) provided January 19, 2022. 
 
You asked the Plan to pay for the acupuncture and infrared light therapy services. You say that the 
documentation supports the medical necessity provided to the enrollee. Please reconsider the previously denied claim. The Plan denied your request. The Plan says that the services do not meet the LCD/NCD coverage 
requirements.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were rendered by a Licensed 
Acupuncturist and not a Physician. Acupuncturists are not recognized by CMS as Medicare providers and are 
not eligible to bill for acupuncture services. The services must be provided by a legally qualified physician 
practicing within the scope of their license. Therefore, we decided that the Plan does not have to pay for the 
acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) and infrared light 
therapy (97026) provided January 19, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you believe that the SNF care should be covered. 
The Plan denied your request. The Plan says that criteria have SNF admission were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have documented skilled nursing needs, in the form of daily wound 
care to deep wounds of his coccyx and ankle. The enrollee does not have documented skilled therapy needs. 
The enrollee appears to have reached a plateau in function. However, daily skilled nursing services are required 
to establish a maintenance program and to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a 
skilled nursing facility (SNF).  
 
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.