Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on April 28, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say that the member is residing at an 
assisted living facility and services were 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 home visit for 
evaluation provided on April 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the service should be approved. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
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 the CT scan have been met. No 
medical records were received for this case after multiple attempts to obtain them. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 26, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral exam (D0150) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for oral exam (D0150) provided on March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that this drug therapy has worked well for the patient. 
The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B 
coverage.t 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided February 10, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says insufficient information was provided. 
 
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 the skilled nursing services have been 
met. No orders or plan of care was provided. The plan requested additional information and none was provided. 
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided February 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical 
pump (E2402) and a wound care set for NPWT, includes all supplies and accessories (A6550). 
 You asked the Plan to pre-approve NPWT and supplies. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request is not medically necessary because 
the records show the pathology report shows the enrollee has a squamous cell carcinoma (SCC) in the wound. 
 
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 NPWT and supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request is not medically necessary because the records show the pathology report 
shows the enrollee has SCC in the wound. The enrollee does not meet criteria for approval of the 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 NPWT and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump (E2402) and a 
wound care set for NPWT, includes all supplies and accessories (A6550).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on March 16, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that it is a 
charge that you do not understand. The Plan denied your request. The Plan says it is not medically necessary 
because there is no documentation of an injury diagnosis billed. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on March 16, 2023.  
 
Benefits for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab injection. 
 
You asked the Plan to pre-approve Durvalumab injection. You say that the requested drug can improve the 
overall survival rate and progression-free survival. The Plan denied your request. The Plan says the requested 
drug is off-label and is not approved by the FDA. 
 
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 Durvalumab injection. Our reviewer 
says that the requested drug, Durvalumab does not meet the criteria for approval. Our physician reviewer found 
the FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia does not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. No literature from Medicare approved cancer journals were submitted for review. The 
requested service cannot be recommended because the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durvalumab injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durvalumab injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on May 10, 2023. 
 
You asked the Plan to pay for the shingle vaccine. You say that you were advised to get the vaccine. The Plan 
denied your request. The Plan says when you get the vaccine at your provider's office, you will pay for the 
entire cost of the vaccine. Then you can ask the Plan to reimburse the payment by using the procedure that is 
described in chapter 7. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingle vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingle 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on May 10, 
2023.  
 
Benefits for the shingle vaccine 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76937 rendered on April 28, 2023. 
 
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 that 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 
code 76937 is "Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access 
sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure)." 
 
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 supported by the medical records. Our reviewer found that the documentation supports 
ultrasound guidance (76937) for access of the radial artery was rendered. There is satisfactory documentation 
that the needle was seen to enter the patent artery under ultrasound guidance. While there is a stipulation that 
the images must be archived, it is not reasonable to require documentation of this in the operative note. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 76937 rendered on April 28, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the SNF care. You say that the services should be covered. The Plan denied your 
request. The Plan says 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 SNF care may require prior authorization. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 skilled nursing facility (SNF) care provided on March 1, 
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 an office visit provided on May 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this should be covered because you felt it was 
medically necessary. The Plan denied your request. The Plan says this provider is out-of-network and 
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 provided on May 16, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyPro motion G device (L8702). 
 
You asked the Plan to pre-approve the MyPro motion G device. You say that the enrollee was referred by their 
physiatrist for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your request. The 
Plan says the MyoPro Motion G device is considered experimental, investigational and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MyPro motion G device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyPro motion G device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 18, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for podiatry services provided on April 18, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for assistant surgeon services for procedure code 63053 rendered on 
January 27, 2023. 
 
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 that procedure code 63053 is not eligible for assistant surgeon reimbursement. 
 
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 
2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be 
paid. In this case, you billed assistant surgery services for CPT code 63053. The Medicare Fee Schedule 
Database contains a surgical indicator of 2 for this procedure.  Our physician reviewer found that the services at 
issue in this case were supported by the medical records. Our reviewer found that the procedure details cite the 
enrollee underwent a lumbar posterior lumbar fusion at one level with an assistant surgeon. Due to the 
complexity of the procedure and the fact that the operative report stated an assistant surgeon was utilized, the 
records do support that CPT 63053 needed surgical assistance. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
assistant surgeon services for procedure code 63053 rendered on January 27, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74230, 74240, 70100, 72040, 
and 70310 performed on March 13, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be covered as 
billed because they are supported in the documentation and were medically necessary. The Plan denied your 
request. The Plan says the radiology services were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate POS. 
 
We looked at the file and Medicare rules. Documentation shows that 74230, 74240, 70100, 72040, and 70310 
were billed with POS 11, indicating an office setting. However, documentation shows the radiology services were performed in a mobile setting. There is no evidence the services were provided in an office setting. Based 
on this information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiology services coded as 74230, 74240, 
70100, 72040, and 70310 performed on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the unattended home sleep test (HST) 
(G0399) provided on May 7, 2023. 
 
You asked the Plan to waive the deductible for the unattended HST. You say that the Plan documents show that 
home sleep studies, colonoscopy and mammography have a $0 copayment, and it does not state that there is a 
deductible and coinsurance for these items. You also say that this claim was processed as part of your 
deductible, as the claim was submitted with an improper code. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the unattended HST was received on May 7, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the unattended home sleep test (HST) (G0399) provided on May 7, 2023.  
 
Your complaint about possible fraudulent billing is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the acupuncture visits provided on April 14, 2023, to 
May 15, 2023.  
 
You asked the Plan to waive the cost share for the acupuncture visits. You say that you do not agree with the 
cost share that you were billed. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for acupuncture for chronic low back pain.  
 
We looked at your contract with the Plan. The Plan contract does not clearly disclose how much enrollees 
should expect to pay for acupuncture. The Plan contract provides conflicting information about your cost-
sharing. While it states that you may be charged Original Medicare cost-sharing, it does not indicate what this 
cost-sharing is, and acupuncture is listed as have a $0 copayment. This means that the Plan did not follow 
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the 
cost share for the acupuncture visits provided on April 14, 2023, to May 15, 2023.   
 
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.