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

 
We decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) provided June 
10, 2023. 
 
You asked the Plan to pay for the diagnostic service. You say that the claim denied as duplicate in error. Please 
review and reprocess the claim for reimbursement. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 29, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the diagnostic service have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) 
provided June 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay the in-network rate for the laboratory service (88305) provided on May 10, 
2023, by the out-of-network provider. 
 
You asked the Plan to pay the in-network rate for the laboratory service. You say that the patient went to an in-
network provider. You say that you are the laboratory that received the specimen for testing. You say that the 
patient did not seek out-of-network services. You also say that this should be reprocessed. The Plan denied 
your request. The Plan says that the out-of-network cost share applied correctly. 
 
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 out -of-network laboratory service by a contract provider. The records show 
that the specimen was collected by the contracted provider and was sent to the out-of-network laboratory. This 
out-of-network provider did not physically see the enrollee. Because the services in dispute were collected by a 
contracted provider, the enrollee would have reasonably believed that any specimens collected would be 
processed by a contracted provider, and that the in-network level of benefits would apply. The file does not 
show that the Plan provided notice that the laboratory services would not be covered under the in-network 
benefit level. Under Medicare rules, this means that the laboratory services are considered approved under the 
in-network benefit level by the plan. Therefore, we decided that the Plan has to pay the in-network rate for the 
laboratory service (88305) provided on May 10, 2023, by the out-of-network provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a raised toilet seat (E0244) purchased April 14, 
2023. 
 
You asked the Plan to reimburse you for a raised toilet seat. You say that you have purchased this item 
previously from the same supplier and was reimbursed. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to reimburse you for a raised toilet seat (E0244) 
purchased April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on May 22, 
2023. 
 You asked the Plan to pay for the medication. You say that you feel that the eye drops should be covered. You 
also say that they were necessary for your post-surgery recovery. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drug 
(A9270) provided on May 22, 2023.  
 
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on June 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
June 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 20, 2022, to 
September 18, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 22, 2022. The NOA was not received by the Plan until February 6, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 20, 2022, to September 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 22, 2021, to 
January 20, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed and reported the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 services have been met. 
Specifically, medical records to support the dates of service at issue have not been provided. 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 home health services provided from December 22, 2021, to 
January 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided May 2, 2023, to May 
18, 2023. 
 
You asked the Plan to pay for the home health care services. You say that you disagree with the Plan's denial. 
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 the home health care services provided May 2, 2023, to May 
18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Actastim-S osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve an Actastim-S osteogenesis stimulator. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Actastim-S osteogenesis stimulator. 
Our reviewer says that an Actastim-S osteogenesis stimulator is not medically reasonable and necessary in this 
case. Our physician reviewer found that limited published, large-scale, long-term peer-reviewed literature 
shows one device being more efficacious than another device for the enrollee's condition. There is indication of 
the different forms of treatment being more efficacious; however, this would not apply to brands of devices. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Actastim-S osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Actastim-S osteogenesis stimulator (E0748).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
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 the laboratory services was not filed until June 19, 2023. 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 laboratory services provided on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary. The 
Plan denied your request. The Plan says your condition does not meet all the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you're receiving appropriate care in current acute care setting as provided by the Plan. 
Documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 63030-50-59 and 63035-RT billed for date of service 
April 26, 2023. 
 
You asked the Plan to pay for codes 63030-50-59 and 63035-RT. You say that you do not believe this claim 
was paid properly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 6, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for codes 63030-50-59 and 63035-RT have not been 
met. Therefore, we decided that the Plan does not have to pay for codes 63030-50-59 and 63035-RT billed for 
date of service April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral infusion pump billed with code B9002 for June 
29, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that these services was used in a SNF. Therefore, we decided that the Plan does not have to pay 
for the enteral infusion pump billed with code B9002 for June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
1, 2023, to January 10, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. 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) provided January 1, 2023, to January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520) provided on June 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do 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 83520 is Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the lab order does not 
specify what test the not otherwise specified code represents. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (83520) provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM sensor. 
 
You asked the Plan to pre-approve a CGM sensor. You say that the item is necessary due to cognitive decline 
and fear of needles. The Plan denied your request. The Plan says that you must use a standalone receiver with 
the CGM. 
 The Plan must follow Medicare rules. Medicare rules say that the CGM supplies are not covered if they will 
not be used in conjunction with a covered CGM receiver.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CGM sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the services 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 practitioner services provided on July 23, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99447 billed for date of service April 7, 
2023. 
 
You asked the Plan to pay for procedure code 99447. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 procedure code 99447 have been met. 
Specifically, medical records for the date of service that support the services at issue have not been provided 
for review. Therefore, we decided that the Plan does not have to pay for procedure code 99447 billed for date 
of service April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Triage test (0363U) provided on May 8, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Triage test for the enrollee. The Plan denied your request. The Plan says this service is not 
covered. Enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being 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 the Cxbladder Triage test (0363U) provided on 
May 8, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 15, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you should not be responsible for the office 
visit charge. You also say that you would like this to be covered. The Plan denied your request. The Plan says 
this is not covered when billed by this type of provider. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on September 15, 2022.