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

 
We decided that the Plan does not have to pay for the durable medical equipment (L1930 and L2820) provided 
on January 18, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (L1930 and L2820) provided on 
January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 6, 2022, to January 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you thought this was 
covered. The Plan denied your request. The Plan says the copayment applied 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 $295 
copayment each day for days 1 to 5 for Medicare-covered hospital care each time you are admitted. 
 
You have been asked to pay $1,180 ($295 x 4 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital Care 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 inpatient hospital stay provided from January 6, 2022, to January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab work provided on April 6, 2022. 
 
You asked the Plan to waive the deductible for lab work. You say that this was an annual visit and that you 
should not have a payment due. The Plan denied your request. The Plan says the deductible applied was 
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 $500 
deductible for Outpatient Diagnostic Tests. Your lab tests, added together, $60.94 was applied to your 
deductible ($8.23 + $10.43 + $7.56 + $5.35 + $13.09 + $5.04 + $3.52 + $2.68 + $5.04 = $60.94). 
 
You have been asked to pay a $60.94 deductible for lab work. Lab work 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 deductible 
for lab work provided on April 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are unsure if you are 
responsible for the charges. The Plan denied your request. The Plan says the copayment applied was 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 $155 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $139.79 for an ultrasound, which is less than your copayment amount. An 
ultrasound 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 an ultrasound provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit on March 02, 2022, to March 
09, 2022. 
 
You asked the Plan to waive the copayments for office visit. You say that you do not feel you should have to 
pay the $45 copay for these three visits as they were all follow up to the surgery on my leg on February 10, 
2022.The Plan denied your request. The Plan says the cost sharing 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 $45 
copayment for each specialist visit for Medicare-covered services. Covered services include consultation, 
diagnosis, and treatment by a specialist. There were 2 visits. $45 + $45 = $90. Therefore, results in the total 
cost sharing amount of $90.  
 
 
 
 You have been asked to pay a $45 copayment for each office visit. 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 office visit on March 02, 2022, to March 09, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (E0147) provided on March 8, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 (E0147) provided on March 8, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services provided to the enrollee on 
January 18, 2022. 
 
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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
 
 CPT 37224: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal angioplasty 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation is not 
sufficiently descriptive to justify coverage of the codes in question. There is unsatisfactory documentation of 
the degree of stenosis and post angioplasty findings. The codes in question include interpretation of the images 
and this is not satisfactorily documented. Therefore, there is insufficient documentation on which to overturn 
the health plans determination. Additionally, the entire right side was essentially treated with the same balloon 
as a single continuous segment. There is no evidence that additional work was done beyond what was already 
covered.  
 
We looked at this coder'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 pay for revascularization services provided to the enrollee on January 18, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cervical fusion for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requirements were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation demonstrates subjective and objective deficits that are corroborated by 
imaging studies. The magnetic resonance imaging (MRI) from 1/20/22 demonstrated moderate to severe 
bilateral foraminal encroachment at both the C5-6 and C6-7 levels with narrowed central canal. Trial and 
failure of conservative treatment modalities have been documented. Therefore, the requested cervical fusion at 
C5-6 and C6-7, in this case, is medically reasonable and necessary.  
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve cervical fusion for the enrollee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on February 04, 2022, to April 
04, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 20% 
coinsurance for intravenous, subcutaneous, and biological Part B drugs. These drugs are covered under Part B 
of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
may be subject to Step Therapy and include drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
The provider billed in the amount of $34 and the allowed amount is $11.74. $11.74 x 20% = $2.35. There were 
3 visits, resulting in the amount of $7.05. $2.35 x 3 = $7.05. Therefore, results in the total cost sharing amount 
of $7.05.   
 You have been asked to pay a 20% coinsurance for injections. Injections fall within the Medicare Part B 
prescription drugs 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 injections on 
February 04, 2022, to April 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0147) provided on May 13, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the walker. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they were provided by an out-
of-network provider. 
 
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 walker (E0147) provided on May 13, 2022 by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose 
monitor (CGM) provided on April 22, 2022. 
 
You asked the Plan to pay for the supply allowance for a therapeutic CGM. The Plan denied your request. The 
Plan says original Medicare is responsible for payment. 
 
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 a supply allowance for a therapeutic continuous glucose 
monitor (CGM) provided on April 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on February 14, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab 
(Keytruda) 
 
You asked the Plan to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested drugs are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Carboplatin, Pemetrexed, and 
Pembrolizumab. Our reviewer says that the documentation does not support that the requested drugs are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of malignant 
neoplasm of overlapping sites of right bronchus and lung (non-small cell lung cancer). Without documentation 
of the tumor's Epidermal growth factor receptor (EGFR)/anaplastic large-cell lymphoma kinase (ALK) 
mutation status the requested use of carboplatin, pemetrexed and pembrolizumab is not FDA-approved for the enrollees diagnosis. Without documentation of the tumor's EGFR/ALK mutation status the requested use of 
carboplatin, pemetrexed and pembrolizumab is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria 
for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin, Pemetrexed, and Pembrolizumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab (Keytruda)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from January 8, 2019, 
through January 18, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not payable as the 
claim was submitted untimely. 
 
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 these services was not filed until April 29, 2022. 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 inpatient hospital care provided from January 8, 2019, through January 18, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, providing 
care in the home; per hour (CPT code S9122). 
 
You asked the Plan to pre-approve the home health aide. You say that the services are necessary. The Plan 
denied your request. The Plan says it is unknown the number of units requested, and there are no provider notes 
sent. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health aide services have been 
met. There are no medical records provided to verify if the services are necessary. Therefore, we decided that 
the Plan does not have to pre-approve home health aide or certified nurse assistant, providing care in the home; 
per hour (CPT code S9122).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (43277) provided December 6, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is not supported in the records. 
 
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 43277 is not supported in the medical record. Specifically, this service is included in 
code 43264 which was also billed. Based on this information, we decided that Medicare rules for coverage of 
the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (43277) provided December 6, 2021.