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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic pressure appliance (E0673) provided October 5, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility or the prescribing physician and do not receive payment from either provider. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic pressure appliance (E0673) 
provided October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on December 28, 
2021. 
 
You asked the Plan to pay for the outpatient hospital services as billed. You say that the records support the 
billed services. The Plan denied your request. The Plan says the outpatient hospital claim includes a device 
dependent procedure code but does not have a corresponding device code. Per edit 92, the claim must be 
returned to provider. 
 The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims are subject to the 
I/OCE which includes many edits to check for billing issues.  
 
We looked at the file and Medicare rules. In this case, according to I/OCE Specifications Version 223.3.R1, 
effective 10/1/2021, edit 92 is invoked when a device dependent procedure is billed without a device code. This 
edit requires the claim to be returned to provider and denied payment.  
 
Review of Medicare sources confirms that code 19281 is a device dependent procedure code. No device code 
was billed. As such, this claim was denied correctly. Based on this information, we decided that Medicare rules 
for coverage of the outpatient hospital services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient hospital services provided on December 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron oral dissolving tablet (ODT) for the 
enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication does not fall under Part B. 
 
 
 
 
 
 
 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 Ondansetron oral dissolving 
tablet (ODT) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cranioplasty for skull defect (62141) provided on 
November 23, 2021. 
 
You asked the Plan to pay for code 62141. You say that the medical records support the billing of code 62141 
provided on November 23, 2021. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 62141 provided on November 23, 2021. 
 
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 62141 is Cranioplasty for skull defect; larger than 5 cm 
diameter. 
 
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 code 62141. Our reviewer says that the medical records do 
not support the billing of code 62141 provided on November 23, 2021. Our reviewer found the enrollee had osteoradionecrosis of the cranial bone with an exposed dura cranial defect with an area of about 4 cm x 4 cm. 
The documentation does not support the billing of code 62141 (Cranioplasty for skull defect; larger than 5 cm 
diameter) provided on November 23, 2021. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 62141 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Cranioplasty for skull defect (62141) provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on December 20, 
2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you did not speak with your 
primary care physician, and you did not want to do a telehealth you wanted a regular appointment. The Plan 
denied your request. The Plan says they received the medical records for the date of service and a telehealth 
visit was rendered by a covering primary care provider. The copayment was reduced to the proper copayment 
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 $10 
copayment for each covered telehealth visit or consultation in an outpatient location with your PCP or other 
primary care provider.  
 
You have been asked to pay a $10 copayment for the telehealth visit. The telehealth 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 a telehealth visit provided on December 20, 2021.  
 
Your complaint about your experience with this provider 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not 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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the records do not clearly explain how the enrollee's screening for aortic aneurysm will change based 
on the results of the genetic testing in question. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the MIST therapy (97610) provided from September 29, 2021, to 
October 8, 2021. 
 
You asked the Plan to pay for the MIST therapy. You say that the provided MIST therapy was medically 
necessary. The Plan denied your request. The Plan says that the provided MIST therapy was not medically 
necessary. 
 
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 pay for the MIST therapy. Our reviewer says that 
the provided MIST therapy was medically necessary. Our physician reviewer found the enrollee has traumatic 
wounds in both lower extremities. MIST Therapy is part of her wound care regimen. The review has 
determined that the MIST therapy provided on September 29, October 1, 4, 6, and 8, 2022 was medically 
reasonable and necessary for the enrollee in this case. 
 
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 MIST therapy have been met. Therefore, we decided that the Plan has to pay 
for the MIST therapy (97610) provided from September 29, 2021, to October 8, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a tangential biopsy, and additional supplies 
provided on October 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, a tangential biopsy, and additional supplies. You say that that you 
are appealing with supporting records. The Plan denied your request. The Plan says based on the information 
currently available, the Plan is unable to authorize coverage for office services, and the decision is based on the 
provider failing to obtain prior authorization before services were rendered. 
 
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 an office visit, a tangential biopsy, and additional 
supplies provided on October 29, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 4, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on November 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not an approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. 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 pay for the 
CxBladder test provided to the enrollee on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee from 
November 2, 2021, to December 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this has processed correctly according to the benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee 
from November 2, 2021, to December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2107, V2762, V2783, V2103) 
provided on February 14, 2022. 
 
You asked the Plan to pay for eyeglasses. You say that you do not understand how these services can be denied 
as "benefit exhausted" when you have not purchased eyeglasses in 2022 prior to this date. The Plan denied your 
request. The Plan says they paid the full allowance for these eyeglasses at the time of purchase, and you are 
responsible for the remaining cost. 
 
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. The Plan covers these services up to $150 each year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid the full $150 allowance for the 
eyeglasses at the time of purchase, and you are being held responsible only for the amount that exceeded this 
benefit allowance. Based on this information, we decided that you were asked to pay the correct amount based 
on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the eyeglasses 
(V2020, V2107, V2762, V2783, V2103) provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 18, 2020, to 
November 25, 2020, as billed with Diagnosis Related Group (DRG) 177. 
 
You asked the Plan to pay for inpatient care billed with DRG 177. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 177 is not supported as the diagnosis of pneumonitis due to inhalation of food and vomit 
(J69.0) is not supported in the medical record as a primary diagnosis. The Plan argues that DRG 189 is more 
appropriate in this case, with J69.0 as a secondary diagnosis and acute and chronic respiratory failure with 
hypoxia (J96.21) re-sequenced as the primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 177. Our 
reviewer says that pneumonitis due to inhalation of food and vomit (J69.0) is not supported as the principal 
diagnosis in this case. Our physician reviewer found that the enrollee presented due to hypoxia after a recent 
discharge from the facility. The enrollees history included chronic obstructive pulmonary disease (COPD) 
with carbon dioxide retention and the enrollee used a Bilevel Positive Airway Pressure (BiPAP) at night. The 
enrollee was noted by staff to have an oxygen saturation in the 50's. Emergency Medical Services (EMS) was 
notified and placed the enrollee on a nonrebreather then transitioned to Continuous Positive Airway Pressure 
(CPAP). On arrival to the emergency department, the enrollee was placed on BiPAP, and the documentation 
noted the enrollee to be tachypneic with a respiratory rate of 32. The enrollee was admitted to the Progressive 
Care Unit and was diagnosed with aspiration pneumonia and a COPD exacerbation. Treatment included 
BiPAP, antibiotics, and bronchodilators. On the day of admission, a rapid response was called as the enrollee 
was noted to have significant difficulty with shortness of breath and was transferred to Intensive Care Unit. 
Review of the medical record acknowledges both diagnoses of aspiration pneumonia and acute respiratory 
failure were valid, documented and present on admission (POA). However, this review has determined that 
J96.21 is the principal diagnosis and J69.0 is a secondary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 177 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided on November 18, 2020, to November 25, 
2020, as billed with Diagnosis Related Group (DRG) 177.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 7, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 
70450-26 is a column II code to column I code 70496. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2302, V2705) provided on 
February 1, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are surprised by this denial because you were 
told that the enrollee has a $350 allowance for eyeglasses, and $64 was paid out-of-pocket at the provider's 
office. The Plan denied your request. The Plan says the total cost of the eyeglasses was $414. The enrollee's 
$350 allowance was applied in full, but $64 of the cost of these eyeglasses exceeded the enrollee's benefit 
allowance. This $64 amount is denied and is the responsibility of the enrollee. 
 
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. The Plan covers these services up to $350 per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the total cost of the eyeglasses purchased on 
February 1, 2022, was $414. The Plan covered $350, but has denied the remaining $64 cost which exceeds this 
allowance. Based on this information, we decided that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. If this amount was paid at the time of purchase, you may not owe any 
additional amount. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2302, 
V2705) provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on 
October 28, 2021, and December 8, 2021. 
 
You asked the Plan to waive the copayments for the office visits. You say that you should not have any 
copayments since you are under a financial assistance program. 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 $50 
copayment for each specialist visit.  
 
The file shows that the Plan approved financial assistance, however it only applies to services received at 
specific locations. The provider in this case is not within this network. Therefore, you have been asked to pay a 
$50 copayment for each of the office visits, for a total of $100. The office visits fall 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 copayments for specialist office visits provided 
on October 28, 2021, and December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low vision therapy and rehabilitation with an 
optometrist. 
 
You asked the Plan to pre-approve low vision therapy and rehabilitation with an optometrist. You say that you 
have macular degeneration, and your vision is getting worse. The Plan denied your request. The Plan says this 
service is not covered when provided by low vision specialist. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a low vision specialist. 
Therefore, we decided that the Plan does not have to pre-approve low vision therapy and rehabilitation with an 
optometrist.