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

 
We decided that the Plan does not have to pay for the fixed height hospital bed with any type side rails and 
mattress (E0250) purchased January 12, 2023. 
 
You asked the Plan to pay for the hospital bed. You say that the durable medical equipment (DME) was 
purchased from a non-approved supplier because both the Plan and the approved vendor were late sending 
notes of approval and DME availability. The Plan denied your request. The Plan says the services was rendered 
by a supplier who is not enrolled or eligible to participate in Medicare. 
 
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 fixed height hospital bed with any 
type side rails and mattress (E0250) purchased January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on February 
03, 2023. 
 
You asked the Plan to pay for transitional care management services. You say that the services should be 
covered. 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 transitional care 
management services provided on February 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A4520, A4554, T4522). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medicare does not cover diapers or incontinence garments. They do not pay 
for the disposable or the reusable garments. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520, 
A4554, T4522).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IGRT. 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your 
request. The Plan says IGRT 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 IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that IGRT is not medically necessary for treatment of this type of skin cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGRT.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 12, 
2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were charged a facility fee by 
mistake. 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 in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $300 copayment for a colonoscopy. This item/service falls within the in-network 
outpatient surgery, including services provided at ambulatory surgical centers 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 record shows this was a diagnostic 
colonoscopy. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy 
provided on January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, benign lesion including margins and repair, 
complex, trunk provided on January 10, 2023. 
 
You asked the Plan to pay for excision, benign lesion including margins and repair, complex, trunk. You say 
that the services should be covered. 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 excision, benign lesion 
including margins and repair, complex, trunk provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC (0315U) provided February 24, 2023. 
 You asked the Plan to pay for the laboratory service. You say that you are requesting the DecisionDx-SCC test 
be reprocessed at the approved Medicare established rate of $3873.00. The Plan denied your request. The Plan 
says this test is not covered and is not medically reasonable and necessary. 
 
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. Per the Plan's GBA MolDX program DEX Diagnostics Exchange, 
DecisionDx-SCC is noncovered by Medicare. Also, per the Plan's policy Proprietary Laboratory Analyses 
(PLA) Codes, 0315U is listed as a PLA noncovered due to experimental/investigational status. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC (0315U) provided February 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on January 4, 2023. 
 
You asked the Plan to pay for the services. 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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the imaging services provided on January 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to care for himself and lives 
alone. The Plan denied your request. The Plan says the request does not meet Medicare guidelines because the 
enrollee no longer requires skilled services on a daily inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 06, 2022. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on October 06, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 29, 2022 to 
February 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 29, 2022 to 
February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI RFA. You say that the enrollee's condition severely affects quality of life. 
The Plan denied your request. The Plan says this is considered not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules state that SI RFA is not considered reasonable and 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 SI RFA. Our reviewer says that the 
enrollee does not meet criteria for SI RFA. Our physician reviewer found sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational.  Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
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 SI RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 01, 2022. 
 
You asked the Plan to pay for the office visit. You say that the provider is in-network with the Plan. 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 office visit provided 
on March 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 20, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are a separately billable 
expense that do not require separate authorization. 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 wound care supplies 
provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 20, 
2023, to March 20, 2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on February 20, 2023, to March 20, 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 December 31, 2022. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you should 
only have a $120 emergency room copayment. 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 $200 
copayment for in-network outpatient diagnostic tests, including CT scans. 
 
You have been asked to pay a $200 copayment for the computed tomography (CT) scan. This item/service falls 
within the in-network outpatient diagnostic tests, including CT scans 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 December 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 23, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device (RAD) with bilevel pressure 
capability (E0471). 
 
You asked the Plan to pre-approve a RAD with bilevel pressure capability (E0471). You say that the requested 
RAD with bilevel pressure capability is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested RAD with bilevel pressure capability.  
 
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 RAD with bilevel pressure capability 
(E0471). Our reviewer says that the enrollee does not meet criteria for the requested RAD with bilevel pressure 
capability. Our physician reviewer found the Plan is correct to deny additional months of coverage of E0471, 
per the apparent lack of re-evaluation of the Beneficiary by the prescriber. This review does note that there are 
automatically generated compliance reports on Airview letterhead which show that the Beneficiary is using the 
RAD enough (average of greater than 7 hours nightly).  However, that is only half of the documentation 
required. It should be noted that the LCD provides for a resumption of coverage if/when the Beneficiarys 
prescriber provides documentation of a face-to-face evaluation documenting improvements of his sleep apnea 
since using the RAD. However, at this time for lack of the specifically required documentation, the enrollee 
does not meet criteria. 
 
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 RAD with bilevel pressure capability (E0471) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a respiratory assist device (RAD) with bilevel pressure 
capability (E0471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen by your provider for 
continuing pain management services. The Plan denied your request. The Plan says enrollees must receive their 
care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit 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 waive the copayment for an office visit provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you had the same service in 2020 
and had no copayment. 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 $45 
copayment for each in-network office visit or telehealth visit to other providers besides a primary care provider 
(PCP). 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each in-
network office visit or telehealth visit to other providers besides a primary care provider (PCP) 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 an office visit provided on March 13, 2023.