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

 
We decided that the Plan does not have to pay for a computed tomographic (CT) angiography of the chest 
provided on January 03, 2023. 
 
You asked the Plan to pay for a computed tomographic (CT) angiography of the chest. You say that this was 
medically necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a computed tomographic 
(CT) angiography of the chest provided on January 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months of continued coverage of home ventilator, any 
type, used with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that this device is used during the awake hours to 
support the enrollee's breathing to increase mobility and decrease their work of breathing. The Plan denied your 
request. The Plan says the request to continue the use of the Life2000 system noninvasive ventilator (NIV) 
requested does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document the modality in which the Life2000 home ventilator is 
being used to clarify that it is not being used in a BiPAP mode. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level 
CPAP therapy for conditions described in this respiratory assist device (RAD) policy will be denied as not 
reasonable and necessary." The LCD requires: "There must be enough detailed information in the medical 
record to justify the treatment selected." The provided records in this case do not provide adequate detailed 
information to meet Medicare criteria for coverage of the ventilator as opposed to a BiPAP device with average 
volume assured pressure support and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months of continued coverage of home ventilator, any type, used with non-invasive 
interface (E0466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88381-XU billed for date of service September 27, 2021.

You asked the Plan to pay for procedure code 88381-XU. You say that this service was reported correctly. The Plan denied your request. The Plan says the payment for code 88381 is included in the payment for code 88377. Although a modifier was used in this case, the documentation does not support that this modifier was used appropriately.

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 88381 is a column II code to column I code 88377; however, 88381 was billed with a modifier.

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 procedure code 88381-XU. Our reviewer says that the XU modifier is not support with code 88381. Our reviewer found the medical documentation does not support the use of 88381 being performed on a separate organism then procedure 88377. Code 88381 cannot be verified as not being combined with 88377.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 88381-XU have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88381-XU billed for date of service September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the clinic visit, the intravenous infusion 
therapy, and the injections provided on October 19, 2021, and November 17, 2021. 
 
You asked the Plan to waive the cost share for the clinic visit, the intravenous infusion therapy, and the 
injections. You say that you had met your maximum out-of-pocket amount. 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 $30 
copayment for physician/practitioner services, including doctors office visits.  
 
The records show you had not met your maximum out-of-pocket amount prior to these services. You have been 
asked to pay a $30 copayment for the clinic visit provided on October 19, 2021. You have also been asked to 
pay a $30 copayment for the intravenous infusion therapy provided on November 17, 2021. This item/service 
falls within the physician/practitioner services, including doctors office visits benefit category.  
 
You have been asked to pay up to 20% coinsurance of the allowed amount for the truxima injection provided 
on October 19, 2021. You have been asked to pay $119.52. You have also been asked to pay 20% coinsurance 
of the allowed amount for the injections. This item/service falls within the Medicare Part B prescription drugs 
benefit category. 
 
Date of Service Item Allowed Amount 20% Coinsurance 
October 19, 2021 Bendeka injection $3,143.36 $628.67 
October 19, 2021 Truxima injection $908.66 $181.73 
November 17, 2021 Bendeka injection $3,143.36 $628.67 
 
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 cost share for the clinic visit, the intravenous infusion therapy, and the 
injections provided on October 19, 2021, and November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377), the 
seat back assembly (K0108), and the bracket assembly (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics, seat back assembly, and the bracket assembly. 
You say that you are requesting reconsideration of the denied authorization. The Plan denied your request. The 
Plan says that the upgraded electronics are not medically necessary. The Plan also says that the requested 
K0108 codes are already included with other approved items. 
 
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 upgraded electronics, seat back 
assembly, and bracket assembly. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has adequate 
strength to manage the standard power drive controls. The requested seat back assembly, height extension is 
unbundled and is included in approved code E1007. The requested bracket assembly, footplate width extension 
is also unbundled and is included in approved code E1012. 
 
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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the upgraded electronics (E2311, E2313, E2377), the seat back assembly (K0108), and 
the bracket assembly (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on December 29, 2022. 
 
You asked the Plan to pay for a physical therapy visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a physical therapy visit 
provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on February 13, 2023. 
 
You asked the Plan to pay for wound care services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care services 
provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and x-ray 
provided on February 7, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visit and x-ray. You say that you thought 
you would only have the office visit 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 $35 
copayment for in-network specialist office visits. Your contract with the Plan also clearly says that you must pay a $20 copayment for each in-network outpatient x-ray.  
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $20 copayment for the x-
ray. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. You 
have been asked to pay a total of $55 ($35 copayment + $20 copayment = $55). 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 the specialist office visit and x-ray provided on February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 23, 2022. 
 
You asked the Plan to pay for lab services. You say that you were advised that you could see any provider you 
wanted. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram provided on November 
04, 2022. 
 
You asked the Plan to waive the copayment for the echocardiogram. You say that you are unsure why you are 
being charged a $85 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 $85 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $85 copayment for the echocardiogram. This item/service 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 the echocardiogram provided on November 04, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023 to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023 to February 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 14, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were bitten by a 
stray dog and could not find the owner. 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for the emergency room visit. 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 the emergency room visit 
provided on January 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 19, 
2022.  
You asked the Plan to pay for subsequent nursing facility care. You say that the claim should be reprocessed. 
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 subsequent nursing facility care provided on December 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Accu-Chek Guide test strips. 
 
You asked the Plan to pre-approve the Accu-Chek Guide test strips. The Plan denied your request. The Plan 
says that the enrollee has not had a therapeutic trial and failure of ONE of the following preferred blood 
glucoses (diabetic) meters by Abbott: FreeStyle Lite Meter, Freestyle Freedom Lite Meter, Precision Xtra 
Meter, or Freestyle Insulinx Meter AND preferred test strips by Abbott: Freestyle Insulinx Test Strips, 
Freestyle Test Strips, Freestyle Lite Test Strips, Freestyle Precision Neo Test Strips, or Precision Xtra Test 
Strips. Conditions for coverage are not met.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans 2023 Evidence of Coverage (EOC) does not list specific 
covered brands. For all people who have diabetes (insulin and non-insulin users). Covered services include: 
Supplies to monitor your blood glucose: Blood You pay a $0 copay glucose monitor, blood glucose test strips, 
lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. 
You can find this information on page 53 of the Plans 2023 EOC. Therefore, we decided that the Plan has to 
pre-approve Accu-Chek Guide test strips.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a SNF stay provided from June 1, 2022, to July 28, 2022. 
 
You asked the Plan to pay for a SNF stay. You say that the enrollee exceeded the 100-day benefit period due to 
a delay in surgery and the $7,500 maximum out-of-pocket was met. The Plan denied your request. The Plan 
says the enrollee exceeded the benefit maximum for SNF services. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 12, 
2022, to May 31, 2022. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for a SNF stay provided from June 1, 2022, to July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine additional months of a home ventilator rental. 
 
You asked the Plan to pre-approve nine additional months of a home ventilator rental. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 nine additional months of a home 
ventilator rental. Our reviewer says that the requested additional rental moths are not supported. Our physician 
reviewer found Medicare does not cover a home ventilator when used at settings that can be provided with a bi-
level positive airway pressure (BiPAP) device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nine additional months of a home ventilator rental have not been met. 
Therefore, we decided that the Plan does not have to pre-approve nine additional months of a home ventilator 
rental.