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

 
We decided that the Plan does not have to pay for lab services (81518) provided on March 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81518) provided on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 13160 and 20702 for date of service June 2, 
2022. 
 
You asked the Plan to pay for procedure codes 13160 and 20702. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. In this case, we have confirmed that code 20702 is an add-on code and has not 
been billed with an appropriate primary procedure code. Based upon this information, we find that Medicare 
coverage criteria for procedure codes 13160 and 20702 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 13160 and 20702 for date of service June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 17, 2022, to December 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the Plan has coverage for durable 
medical equipment and the charges are medically necessary, therefore all charges should be paid in full. 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 November 17, 2022, to December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a compression burn garment (A6501) provided on February 
10, 2023. You asked the Plan to pay for the compression garment. You say that the compression garment is a vital part of 
treatment to maintain lymphedema. The Plan denied your request. The Plan says the denial of payment is 
correct, because there is no documentation this enrollee is being treated for an open ulcer. 
 
The Plan follows Medicare rules. Medicare rules say that a compression burn garments (A6501) are covered 
when they are used to reduce hypertrophic scarring and joint contractures following a burn injury.  
 
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 compression garment. Our reviewer says 
that the criteria for coverage was not met. Our physician reviewer found that there is no documentation 
showing the enrollee has a qualifying wound. Per the enrollee's appeal note, the compression garment is 
requested as a preventive treatment to maintain their lymphedema status. The review has determined that the 
records provided do not support that the requested compression burn garment (A6501) is to be used to reduce 
hypertrophic scarring and joint contractures following a burn injury. 
 
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 compression garment have not been met. Therefore, we decided that the 
Plan does not have to pay for a compression burn garment (A6501) provided on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis service (81003) provided on September 30, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you request reprocessing of this claim and 
pay per Plan benefits as this is a reimbursable charge for a participating provider. The Plan denied your request. 
The Plan says 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 urinalysis service (81003) provided on 
September 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Vacuum socket system (called a vacuum-assisted socket 
system or VASS) and an extra covering for the enrollee's prosthetic leg (L5781). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says that this vacuum socket is experimental and cannot be approved. 
 
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 pre-approve the items. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found any experienced clinician in this space knows that VASS is very much in the mainstream of 
standards of prosthetic care. Though Medicare policy is technically non-specific about coverage rules for 
VASS, it does in fact routinely cover it, meaning it cannot be on its face experimental.  For this enrollee and 
many like them, this technology materially complies with the general reasonable and necessary criteria. 
Furthermore, the Plan also denied the flexible outer cover, asserting that it exceeds her needs particularly given 
the approval of L5704. The certified prosthetists/orthotists (CPOs) is appealing the denial of L5781, but not 
challenging the denial of L5962.  
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
the Vacuum socket system (called a vacuum-assisted socket system or VASS) and an extra covering for the 
enrollee's prosthetic leg (L5781).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided from November 18, 
2020, to December 1, 2020. 
 
You asked the Plan to pay for PT services. You say that these claims were submitted timely. The Plan denied 
your request. The Plan says the claim was not submitted within the timely filing limit. 
 
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 PT services was not filed until December 3, 2021. 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 physical therapy (PT) services provided from November 18, 2020, to December 
1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the enrollee needs a hip replacement. 
The Plan denied your request. The Plan says the medical criteria for this procedure have not been met. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident (including but not limited to any 
injections for the right hip). With the subjective/objective findings of the right hip not clearly demonstrating 
significant impairment, failure of all available conservative measures should typically be documented. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee arthroplasty. 
 
You asked the Plan to pre-approve right knee arthroplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 right knee arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested right knee arthroplasty 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 right knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visits provided on May 08, 2023, to 
June 05, 2023. 
 
You asked the Plan to pay for the chiropractic office visits. 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 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 the chiropractic office 
visits provided on May 08, 2023, to June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on August 31, 2022. 
 
You asked the Plan to pay for the specialist office visit. You say that the providers office said they take your 
insurance. 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 the specialist office visit 
provided on August 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 83735 and 84132 billed for August 3, 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 that procedure codes 83735 and 84132 have a Physician Fee Schedule status indicator of 
X and are statutorily excluded. 
 
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 Plan states that codes 83735 and 84132 have a status indicator of X on the 
Physician Fee Schedule. While this is true, these codes are payable under the Laboratory Fee Schedule. The 
Plan has not provided any documentation to support that the codes are not payable as billed. Therefore, we 
decided that the Plan has to pay for procedure codes 83735 and 84132 billed for August 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87634, 87798, 87486, 87498, 87502, 87634, 
87640, 87651, U0003 and U0005) provided on January 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87634, 87798, 87486, 87498, 87502, 87634, 87640, 87651, 
U0003 and U0005) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye examination provided on October 25, 2022. 
 
You asked the Plan to pay for the eye examination. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that authorization was not on file for the non-participating provider. 
 
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 Plan did not submit a full Evidence of Coverage. This means we could not 
determine if the denial was appropriate. Furthermore, the Plan submitted the Annual Notice of Changes for 
2022 which does not show that authorization would be needed for an outpatient eye examination. Therefore, 
we decided that the Plan has to pay for the eye examination provided on October 25, 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 the infrared therapy (97026) provided on March 14, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.  
 
The Plan must follow Medicare rules. The rules say that that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary.  
  
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, Medicare rules say that there is sufficient evidence to 
conclude that the use of infrared therapy devices and any related accessories is not reasonable and necessary.  
Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on  
March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic propulsion tire (E2211) and an insert for a 
pneumatic propulsion tire (E2213). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you request reconsideration 
and have submitted documents for review. The Plan denied your request. The Plan says the pneumatic tire and 
inserts do not serve a primary medical need since the requested wheelchair includes standard tires which would 
work inside the home. Pneumatic tires are primary for outside rough terrain. 
 
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 pneumatic propulsion tire (E2211) and an insert for a pneumatic propulsion tire (E2213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review indicates that the enrollee is medically stable and has been 
provided medical clearance for the elective procedure. The planned procedure is not listed on the CMS 
Inpatient Only List and is currently approved as an ambulatory procedure. There is no documentation provided 
indicating medical necessity for an inpatient admission for the elective procedure. The review has determined 
that the record does not show that at the time of inpatient admission the admitting physician would reasonably 
expect that the enrollee's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.