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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on May 
19, 2023, through June 13, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
request reconsideration of payment on this claim. The Plan denied your request. The Plan says the requested 
PCD is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 used for a preventative service or 
function are excluded from coverage. 
 
 
 
 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 on May 19, 2023, through June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services billed with code 61781 for date 
of service August 23, 2023. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services provided are not payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services billed 
with code 61781 for date of service August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair calf rest (E0995). 
 
You asked the Plan to pre-approve a wheelchair calf rest. The Plan denied your request. The Plan says this is a 
bundled service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Column II code is included in the allowance for 
the corresponding Column I code when provided at the same time. When multiple codes are listed in column I, 
all the codes in column II relate to each code in column I.  
 
We looked at the file and Medicare rules. In this case, the requested code, E0995, is a column II code to 
column I code K0856, which was approved by the Plan. As such, the requested calf rest is considered bundled 
into the wheelchair approval, and it not separately payable. Based on this information, we decided that 
Medicare rules for coverage of a wheelchair calf rest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a wheelchair calf rest (E0995).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on April 30, 
2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the chronic care management services. You say that the provider was the only 
provider to render services at the time. The Plan denied your request. The Plan says the services do not meet 
the criteria for coverage. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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. The services provided were not dental services. Therefore, we 
decided that the Plan does not have to pay for the chronic care management services provided on April 30, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA test (81479) provided June 7, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please reconsider and reprocess this claim. 
PrismRA is only available through you and should be considered medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this test has not completed the required assessment and therefore 
is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records and the data provided substantiate that the testing was medically necessary 
and reasonable. 
 
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 laboratory testing have been met. Therefore, we decided that the Plan has to 
pay for the PrismRA test (81479) provided June 7, 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 reduce the copayment for each nerve block injection provided on 
February 09, 2023, to May 11, 2023. 
 
You asked the Plan to reduce the copayment for each nerve block injection. You say that you think that the 
copayment should be lower. 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 $270 
copayment for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital.  
You have been asked to pay a $270 copayment for each nerve block injection. This item/service falls within the 
other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, 
and outpatient surgery performed in an outpatient hospital 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 amount you owe is $810 ($270 
copayment x 3 services = $810). Therefore, we decided that the Plan does not have to reduce the copayment for 
each nerve block injection provided on February 09, 2023, to May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 24, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
covered. 
 
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 file shows that the billed unique identifier, Z00D5, is 
not covered for the billed testing with code 81479. Based on this information, we decided that Medicare rules 
for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on September 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 4, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a durable medical 
equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code S9083. You say that these services were medically necessary and 
should be paid. 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 S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025), bifocal lens (V2200), and anti-
reflective coating (V2750) purchased on July 10, 2023. 
 
You asked the Plan to pay for the eyewear. You say that you have not received any finical help during 2023. 
You also say that you are a widower living on $2,028 social security a month. The Plan denied your request. 
The Plan says you have exceeded your calendar year maximum for this benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $150 per calendar year for eyewear which is applied at the time of service, and you 
will be responsible to pay for any remaining balance. 
 
 
 We looked at the file and the Plan's rules. The record shows that you received eyewear on July 13, 2023, which 
the Plan processed first and applied your full $150 eyewear benefit towards. Thus, your 2023 eyewear 
allowance has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames 
(V2025), bifocal lens (V2200), and anti-reflective coating (V2750) purchased on July 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from December 5, 2022, 
to December 8, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was revised from DRG 193 to 194. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.21. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollee was treated in the hospital for cough and shortness of breath, diagnosed as 
pneumonia. The evaluation and workup revealed Sp02 92-94% on baseline oxygen support (3L/m), normal 
pulmonary effort, wheezing, but some accessory muscle use. The enrollee did not require bilevel positive 
airway pressure (BiPAP) or vent support and didn't require high flow oxygen. There were no arterial blood gas 
results to confirm hypoxia. The enrollee appeared to be near baseline respiratory status. Therefore, the 
diagnosis code J96.21 (acute respiratory failure) is not sufficiently supported for this admission, making DRG 
194 more appropriate.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from December 5, 2022, to December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
25, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the subsequent nursing facility care provided on September 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 8, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that due to being legally blind, you have not had 
denials for vision health. You also say that you would like a redetermination done for the services. The Plan 
denied your request. The Plan says you received a routine eye exam on September 8, 2023. The Plan also says 
that you have exceeded your limit of 1 routine eye exam per year. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record does not show that this eye refraction was performed with 
a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on September 8, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 19, 2022. 
 
You asked the Plan to pay for the services. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 9, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided on 
April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital visit provided on 
August 31, 2023, to September 01, 2023. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that you believe that claim 
was coded incorrectly and you did not have a choice to stay overnight. 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 $255 
copayment for outpatient hospital services. 
 
You have been asked to pay a $255 copayment for the outpatient hospital visit. This item/service falls within 
the outpatient hospital services 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 outpatient hospital visit provided on August 31, 2023, to September 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging services 
provided on August 08, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging services. You say that you 
were told that the service would be fully covered. 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for the magnetic resonance imaging services. 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. However, since the allowed amount is 
less than the standard copayment, you only owe $253.10. Therefore, we decided that the Plan does not have to 
waive the copayment for the magnetic resonance imaging services provided on August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 21, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you would like the medical 
records to be reviewed to show proof of delivery. You also say that you would like the claim to be reprocessed 
and paid. The Plan denied your request. The Plan says Medicare rules say that no provider or supplier shall 
receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you feel like 
there has been an overpayment. 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 $225 
copayment for in-network outpatient diagnostic tests, including a CT scan. 
 
You have been asked to pay a $225 copayment for the computed tomography (CT) scan. This item/service falls 
within the in-network outpatient diagnostic tests, including a CT scan 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 computed tomography (CT) scan provided on July 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (44213, 44180) provided on June 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as 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, we have confirmed that code 44213 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. We have also confirmed that code 44180 is a column 
two code to column one code 44626 with a modifier indicator of 0. The column two code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (44213, 44180) provided on June 8, 2023.