Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the treatment was medically appropriate. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 We asked our physician 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 billed service. Our reviewer found that the enrollee 
presented for atypical chest pain that was intermittent for a couple months. The records do not support a high 
level of medical decision making. Therefore, the billed code is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99285 billed for date of service May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care to regain strength and endurance. 
The Plan denied your request. The Plan says your condition does not meet the criteria for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on July 19, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that you need to submit the claim to Part D 
Pharmacy benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on July 
19, 2023.  
 
Benefits for immunization services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart for calcium scoring. 
 
You asked the Plan to pre-approve a CT scan of the heart for calcium scoring. You say that there is a set 
algorithm in the guidelines that states if the patient is moderate risk to use a calcium score to help stratify 
whether they need a statin. You say that the enrollee meets those guidelines. The Plan denied your request. The 
Plan says a CT scan of the heart for calcium scoring is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the heart for calcium 
scoring. Our reviewer says that a CT scan of the heart for calcium scoring is not medically necessary. Our 
physician reviewer found there is insufficient support in the peer-reviewed literature demonstrating a 
significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding 
optimal management of the enrollee. As such, CT imaging of the heart without contrast material with 
quantitative evaluation of coronary calcium is considered experimental and investigational for the evaluation 
and management of the enrollee's medical 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 a CT scan of the heart for calcium scoring have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the heart for calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery system (E0636, E1399) purchased on 
July 28, 2023. 
 
You asked the Plan to pay for the face down recovery system. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 pay for the face down recovery system (E0636, E1399) purchased on 
July 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  ER services provided on June 9, 2023. 
 
You asked the Plan to waive the copayment for  ER services. You say that you were told to go here to get a 
computed tomography (CT) scan done. 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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for ER services. This item/service falls within the emergency 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  ER services provided on June 9, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a universal serial bus (USB) charger port (K0108) and 
repair or non-routine service for durable medical equipment (DME) other than oxygen equipment (K0739). 
 
  You asked the Plan to pre-approve a USB charger port and repair or non-routine service for DME. You say that 
you would like the documentation provided for code K0108 to be reconsidered as it is to meet the enrollee's 
current medical, mobility and functional needs. The Plan denied your request. The Plan says the charger port 
does not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that Medicare does not pay for the repair of previously denied 
equipment. 
 
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. Specifically, 
since the USB charger port does not serve a medical purpose and is denied, the repair is also denied. Therefore, 
we decided that the Plan does not have to pre-approve a universal serial bus (USB) charger port (K0108) and 
repair or non-routine service for durable medical equipment (DME) other than oxygen equipment (K0739).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that the test is a proven covered benefit. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided on June 7, 2023. 
 
You asked the Plan to pay for home infusion. You say that a participating provider referred the enrollee to you. 
The Plan denied your request. The Plan says the enrollee's primary insurance carrier does not yet have a claim 
for this service. 
 
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 contacted the 
enrollees primary insurance carrier and directed you to submit the claim to the primary insurance carrier. As 
the secondary insurer, the Plan cannot be held responsible for home infusion until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for home infusion 
services provided on June 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
You asked the Plan to pay for the SNF care. You say that services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says SNF services are not a 
covered benefit while on hospice. 
 
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. Medicare rules say that the 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 those 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 (SNF) care provided from May 18, 2023, to June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device billed for date of service April 
13, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records provided do not show that a traction device was 
part of the treatment plan. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the cervical traction device billed for 
date of service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A9270 billed for date of service April 29, 2023, to May 
4, 2023. 
 
You asked the Plan to pay for code A9270. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says procedure code A9270 is not payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that code A9270 has a status indicator of N on the Physician Fee Schedule. This means that procedure code A9270 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code A9270 have not been met. Therefore, we decided that the Plan does not have to pay for code A9270 
billed for date of service April 29, 2023, to May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service 
February 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT code 99309 and G8427 is not supported in the medical record. The codes at issue were billed 
with the -HE modifier, which is not among those suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99309 and G8427 billed for date of service February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network automatic external 
defibrillator provided on June 24, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network automatic external defibrillator. You say 
that you did not keep this item and want to have this fee waived. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an out-of-network automatic external defibrillator. This 
item/service falls within the durable medical equipment (DME) and related 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. The total you owe is 
$602.82 ($3014.09 x 20% = $602.82 ). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an out-of-network automatic external defibrillator provided on June 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 16, 2023, 
to March 17, 2023.  
 
You asked the Plan to pay for home health services. You say that you are appealing the denied payment with 
medical records to support the services billed. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the initial plan of 
care, subsequent occupational therapy evaluation, subsequent physical therapy evaluation and subsequent order 
do not contain a providers signature. As such, the services were not properly ordered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from February 16, 2023, to March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 29, 2023, billed with 
procedure code 99204. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the history is insufficient, 
documentation does not support a moderate level of decision making. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 29, 2023, billed with procedure code 
99204.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Lite test strips 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that the enrollee prefers the Freestyle 
Lite test strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC 
are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve the Freestyle 
Lite test strips
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantation of the Optimizer Smart implantable pulse 
generator (0408T) and associated services provided on May 31, 2023. 
 
You asked the Plan to pay for the Optimizer Smart device. You say that the services were medically necessary. 
The Plan denied your request. The Plan says there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Optimizer Smart device in patient 
management. 
 
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 Optimizer Smart device. Our reviewer 
says that the Optimizer Smart device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the clinical studies led to Food and Drug Administration (FDA) approval in 
2019, cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, 
the reviewer found that the Optimizer Smart device is not medically reasonable or 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 Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pay for the implantation of the Optimizer Smart implantable pulse generator (0408T) and 
associated services provided on May 31, 2023.