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

 
We decided that the Plan does not have to pay for the office visit and echocardiogram (ECHO) services 
provided on March 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and ECHO services. You say that you were not told about any out 
of network issues. The Plan denied your request. The Plan says you must receive your 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 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 office visit and echocardiogram (ECHO) 
services provided on March 10, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LymphaPress 4-chambered pneumatic compression 
devices (E0651, E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve LymphaPress. You say that the requested items are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not been 
met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The provider at issue in this case is not a network provider with the Plan. 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 LymphaPress. Our reviewer says that an OON exception is not medically 
necessary in this case. Our physician reviewer found that the enrollee has lymphedema and has tried 2 or more 
months of medical gradient compression stockings, elevation and exercise without improvement. The enrollee 
has had a successful trial with the LymphaPress E0651 with 4 chambers. This is the only equipment the 
enrollee has tolerated. However, it appears that an in-network alternative to the requested provider is available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LymphaPress have not been met. The Plan has network providers available who 
can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve LymphaPress. Therefore, we decided that the Plan does not have to pre-approve LymphaPress 4-
chambered pneumatic compression devices (E0651, E0667) to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computerized non-surgical spinal decompression. 
 
You asked the Plan to pre-approve computerized non-surgical spinal decompression. You say that 
computerized non-surgical spinal decompression.is medically necessary. The Plan denied your request. The 
Plan says computerized non-surgical spinal decompression is considered experimental and investigational 
because there is insufficient scientific evidence to establish the effectiveness of this treatment modality 
 
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 computerized non-surgical spinal 
decompression. Our reviewer says that the requested computerized non-surgical spinal decompression.is not 
considered medically reasonable and necessary. Our physician reviewer found that you have chronic low back 
pain that has not responded to conservative therapy. Computerized non-surgical spinal decompression is considered experimental and investigational. Therefore, the request is deemed not medically reasonable and 
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 computerized non-surgical spinal decompression have not been met. Therefore, 
we decided that the Plan does not have to pre-approve computerized non-surgical spinal decompression.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve home infusion services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated 
within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home infusion services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81529 billed for date of service August 29, 2023. 
 
You asked the Plan to pay for the billed code. You say that the claim was denied in error. The Plan denied your 
request. The Plan says that the number of units exceed the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81529 is 1. The MAI value for this code is 2. The documentation provided 
in the case file shows 1 unit of this code billed. Based on this information, we decided that Medicare rules for 
coverage of the billed code have been met. Therefore, we decided that the Plan has to pay for procedure code 
81529 billed for date of service August 29, 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 waive the copayment for the office visit provided on July 31, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are confused that you have a 
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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on July 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 22, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not understand the cost 
sharing. 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 20% 
coinsurance for in-network Medicare Part B drugs, including chemotherapy drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the in-network 
Medicare Part B drugs, including chemotherapy drugs 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 you owe is $143.87 ($719.33 allowed amount x 20% = $143.87). Therefore, we decided that the Plan does not have to waive the coinsurance for an injection 
provided on June 22, 2023.
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 patient requires a multi-disciplinary 
approach to help manage their multiple medically complex issues. You also say that an LTACH is the most 
appropriate setting for the patient to continue to receive ongoing care. The Plan denied your request. The Plan 
says the criteria for admission to the LTACH have not been met. 
 
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 services the patient requires are available at the health care setting being offered 
by the health plan (the acute care hospital where they are currently receiving care). Ongoing care has not been 
denied at the acute care hospital. Our reviewer found that there is no clear therapeutic advantage of an LTACH 
over the existing hospital environment. The requested services are medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the patient and able to be furnished safely and effectively only on 
an inpatient basis. Our physician reviewer also found that these services can be obtained at the acute care 
hospital where the enrollee is currently receiving care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on September 
20, 2023. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you were informed prior to the 
test that you would only have to pay for the $300 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Part B drugs. This item/service falls within the Medicare 
Part B prescription drugs 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 you owe is $947.61 ($4,738.05 allowed amount x 20% = $947.61). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on September 
20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 25, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you do not feel the visit was worth 
the claim or copay. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on September 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 23, 2023, to July 
12, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of code 037G3ZZ. 
 
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 037G3ZZ. 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 submitted records do not support the billing of code 037G3ZZ. Our physician reviewer found the 
submitted medical records do not contain any documentation of the performance of a dilation of intracranial 
artery with percutaneous approach. Billed procedure code 037G3ZZ and DRG are therefore not supported.  
 
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 provided on June 23, 2023, to July 12, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676), a segmental 
pneumatic appliance for use with pneumatic compressor, full arm (E0668) and a segmental gradient pressure 
pneumatic appliance, half leg (E0673) provided on April 14, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and garments. You say that the claim should not 
have denied. You would like the Plan to review the medical records and process the claim for payment. The 
Plan denied your request. The Plan says the PCD was ordered for deep vein thrombosis prevention following 
surgery. Items that are used for a preventative service or function are excluded from coverage. 
 
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. 
 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 (E0676), a segmental pneumatic appliance for use with pneumatic 
compressor, full arm (E0668) and a segmental gradient pressure pneumatic appliance, half leg (E0673) 
provided on April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records support the need 
for this service. The Plan denied your request. The Plan says this procedure 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 the surgical procedure. Our reviewer 
says that the requested total shoulder arthroplasty is 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. The trial and failure of any formal 
physical therapy, prescription medications, and/or injection therapy is not evident. Additionally, the provided 
imaging studies did not corroborate rotator cuff pathology. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the reviewer found that the requested total shoulder 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total shoulder arthroplasty (23472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory suction pump (E0600) provided on August 19, 
2023 provided on August 19, 2023. 
 
You asked the Plan to pay for a respiratory suction pump (E0600) provided on August 19, 2023. You say that 
you disagree with the denial and request reconsideration. 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 a respiratory suction 
pump (E0600) provided on August 19, 2023 provided on August 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on November 28, 
2022, to November 29, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the 
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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for emergency care. This item/service falls within the emergency 
care 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 emergency care provided on 
November 28, 2022, to November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services from May 24, 2023, to June 22, 2023. 
 
You asked the Plan to pay for the SNF services . You say that the services which the enrollee required and 
received during the period in question are coverable. The Plan denied your request. The Plan says that the 
enrollee's 100-day SNF benefit was exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 6, 2022, 
through May 23, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may have needed skilled care, the Plan is not required to pay for more than 100 days of 
SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, 
we decided that the Plan does not have to pay for the SNF services from May 24, 2023, to June 22, 2023.