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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
28, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 28, 2022.
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 the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving the care needed in the hospital where they are 
now and there is no need to transfer to the LTACH at this time. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee continues to require care at an acute care hospital. The enrollee can receive 
further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) and administration 
(90471) provided on November 1, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you were only reimbursed a small portion of 
the cost. You say that you were told that this would be covered. You also say that you should be reimbursed an 
additional amount. The Plan denied your request. The Plan says the vaccine services are not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) 
and administration (90471) provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
12, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99292 billed for date of service December 16, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that a claim for 
the primary service was not received. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is supported in the medical record. The claim information in the case file shows 
that primary procedure code, 99291, was provided on the date of service at issue, by a different provider within 
the same group. Any additional practitioner in the same specialty and the same group furnishing care 
concurrently to the same patient on the same date report their time using the code for subsequent time intervals 
(CPT code 99292). Based on this information, we decided that Medicare rules for coverage have been met. 
Therefore, we decided that the Plan has to pay for procedure code 99292 billed for date of service December 
16, 2022.  
 
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 procedure code 99310-25 billed for date of service October 
3, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code cannot 
be separately reimbursed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that evaluation and management code 99310-25 was not a significant, separately identifiable service 
from minor procedure codes 11042, 11044, or 20240. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99310-25 billed for date of service October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that to be eligible for coverage of a CGM and related 
supplies, the beneficiary must meet certain initial coverage criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Specifically, the enrollee is not on insulin or has documentation 
showing a history of problematic hypoglycemia. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (code L0456) provided on November 2, 2022. 
 
You asked the Plan to pay for the back brace. You say that the records support the need for this item. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the item at issue is a back brace.  None of the medical records provided mention any issues or problems related to the patient's back. Therefore, we decided that the Plan does not have to pay for the 
back brace (code L0456) provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio device provided on January 6, 2023. 
 
You asked the Plan to pay for the Cala Trio device. You say that the enrollee has been using this device and 
seeing improvement and control over their hands' essential tremor. You also say that this should be covered. 
The Plan denied your request. The Plan says this device is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Cala Trio device. Our reviewer says that 
the Cala Trio device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the Cala Trio device at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cala Trio device provided on January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800, E1399). 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot get around the stores or flea 
markets because you are unable to walk far. You need the requested scooter. The Plan denied your request. The 
Plan says the requested power scooter is being requested for use only outside of the home. This a not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800, E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided medical records to 
support payment. 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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II 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 procedure code 0245U billed for date of service July 14, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient rehabilitation services provided from March 22, 2021, to 
March 31, 2021. 
 
You asked the Plan to pay for outpatient rehabilitation services. You say that this claim processed under the 
wrong insurance. The Plan denied your request. The Plan says that the denial of payment for these services is 
correct. 
 
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. The only denial reason given by the Plan is that these charges exceed the fee 
schedule/maximum allowable amount for the billed services. However, the Plan has not shown that any 
payment was made for these services. The Plan has not offered any other rationale or evidence to support a 
denial of payment. Therefore, the Plan has not shown that its decision to deny payment for these services is 
correct or justified. Therefore, we decided that the Plan has to pay for outpatient rehabilitation services 
provided from March 22, 2021, to March 31, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to see your provider. The Plan denied your request. The Plan says the requested trip exceeds 
your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request for six additional months rental 
exceeds the benefit allowance. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
Medicare rules also say that if DME serves the same purpose as equipment already available to an enrollee, it is 
not considered reasonable and necessary. 
 
The file shows that the enrollee received a standard wheelchair in September 2021. The records show that the 
current wheelchair is confirmed to be in good working order. There is no documentation from the provider of 
the need for a new wheelchair. This means that Medicare rules for coverage of a standard wheelchair have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the requested block is the first step to 
a more permanent procedure, genicular radiofrequency ablation. You say that the enrollee's pain is a persistent 
7 out of 10. You also say that the enrollee has tried and failed conservative management. The Plan denied your 
request. The Plan says the requested block is not medically necessary. 
 
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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is considered experimental and investigational. The 
reviewer found that the role of genicular nerve blocks and of RFA in the post total knee replacement setting is the subject of ongoing clinical trials. Therefore, the reviewer found that the requested service is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2023. 
 
You asked the Plan to pay for the office visit. You say that this was a normal doctors visit with the 
pulmonologist. The Plan denied your request. The Plan says the care available in-Plan. 
 
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 
service 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 an office visit provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on November 1, 2022. 
We also decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 1, 2022.  
 
You asked the Plan to waive the cost share for the betamethasone acetate injection and specialist office visit. 
You say that there is an additional charge on this claim. The Plan denied your request. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injection provided on November 1, 
2022.  
You have been asked to pay 20% coinsurance for the drug injection. According to Medicare, the injection 
(code J0702) is considered a packaged code and is not separately payable. This code is also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the drug 
injection provided on November 1, 2022. 
We also decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on November 1, 2022. 
 
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 $20 
copayment for each specialist office visit.  
 
You have been asked to pay a $20 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 specialist office visit provided on November 1, 2022. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport billed with code A0429 for July 11, 
2022. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that ambulance claims must be billed with an origin or 
destination code.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid destination 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the ambulance transport billed with code 
A0429 for July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9270 billed for date of service October 9, 
2022 to October 10, 2022. 
 
You asked the Plan to pay for procedure code A9270. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
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 A9270 has a Status Indicator of N on the Physician Fee Schedule. This means that procedure code A9270 is not covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code A9270 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A9270 billed for date of service October 9, 2022 to October 10, 2022.