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

 
We decided that the Plan does not have to provide a continuous glucose monitor. 
 
You asked the Plan to provide a continuous glucose monitor. You say that it is becoming difficult to the 
enrollee to check sugars as needed. The Plan denied your request. The Plan says the blood glucose logs 
submitted shows the enrollee is not testing 4 or more times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or requires frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a 
continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound 
care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with 
the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not 
 
 
require the necessary services on an inpatient basis, in a 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 continuation of SNF care, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
February 12, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The 
Plan says that this claim was processed 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 $275 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls 
within the one-way Medicare-covered ground trip 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 ambulance transport provided on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on April 28, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.  
 
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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $94 which is less than your copayment amount of $160 for an ultrasound. An 
ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 an ultrasound provided by a participating provider on April 
28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
swelling of the legs. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of your CPAP rental. 
 
 
 
You asked the Plan to pre-approve continuation of your CPAP rental. You say that you need the CPAP for life 
sustaining purposes. The Plan denied your request. The Plan says the compliance report shows that you are not 
using your CPAP as prescribed. 
 
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. The Compliance Report shows you are not compliant with CPAP 
usage. Based on this information, we decided that Medicare rules for coverage of continuation of CPAP rental 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of your 
CPAP rental.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided to the enrollee on December 2, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 practitioner services provided 
to the enrollee on December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiogram (TTE) rendered on 
March 12, 2020. 
 
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 procedure code 93312 was billed with an inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier XU is used in lieu of modifier 59. 
 
We looked at the file and Medicare rules. The file shows that the provider billed code 93312 with both the -59 
and -XU modifier. It is inappropriate to bill with both of these modifiers on one code. Therefore, we decided 
that the Plan does not have to pay for the transesophageal echocardiogram (TTE) rendered on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the replacement of a central venous 
catheter provided on September 9, 2020. 
 
You asked the Plan to waive the copayment for the replacement of a central venous catheter. You say that you 
received a different device than what you were originally told. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $50 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $50 copayment for the replacement of a central venous catheter. The 
replacement of a central venous catheter falls within the outpatient surgery, including services provided at 
hospital outpatient facilities and 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the replacement of a central venous catheter provided on September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy services provided on July 27, 2020. 
 
You asked the Plan to pay for the services provided. You say that if you were told that your plan would not 
cover provider who you went to in the past, you would not have gone to the provider again. The Plan denied 
your request. The Plan says the service is not covered. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
We looked at the file and the rules. The provider in this case is not a network provider. Your plan says that you 
must use a network provider for your care and services. Therefore, we decided that the Plan does not have to 
pay for the massage therapy services provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (CPT 88305) provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88305 is "Level IV - Surgical pathology, gross and 
microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis 
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical 
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy 
Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, 
fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection 
Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge 
resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy 
Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or 
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary 
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, 
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, 
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other 
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than 
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy 
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse 
Vagina, biopsy Vulva/labia, biopsy." 
 
 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records submitted. Our physician reviewer 
found the documentation is insufficient in regard to gross examination, to support coverage for 88305 Level 
IV. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (CPT 88305) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on January 23, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says to report a 
comprehensive genomic panel, providers should use CPT code 81479. 
 
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 the testing at issue is not supported in the medical record. The records provided do not include the 
results of the testing to show the services were provided. The records provided did not show that the physician 
ordered the testing at issue as part of the enrollees care plan. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intense therapy so you can recover faster. 
The Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. 
Your medical conditions are stable. There are medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that your previous dentures no 
longer fit properly. The Plan denied your request. The Plan says this service is only covered 1 time in a 60 
month period. The Plan also says that you have already received this service within the last 60 months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial dentures are limited 
to 1 per 60 months. The record shows that you received a mandibular partial denture (D5214) on August 9, 
2017, and your mandibular partial denture benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 3, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11.  Also, the laboratory results submitted indicate the 
specimen was collected on May 6, 2020 and received by the lab on May 7, 2020. Of note, the enrollee resides 
in Illinois and the billing lab is in Florida. The billed code cannot be verified.  It is noted multiple attempts 
were made to obtain additional information from the provider 
 
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 POS code submitted is not 
supported by the medical records. Based on this information, we decided that Medicare rules for coverage of 
this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve L5986. We decided that the Plan does not have to pre-approve 
L5981.  
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan says that this is 
not medically necessary. 
 
We decided that the Plan has to pre-approve L5986.  
 
The Plan follows Medicare rules. Medicare rules say that L5986 is covered for enrollees with a functional level 
of 2 or above. 
 
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 for L5986 Our reviewer says that there is 
documentation of a functional level of 2 or above that would indicate the requested accessory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5986 have been met. Therefore, we decided that the Plan has to pre-approve 
L5986.  
 
We also decided that the Plan does not have to pre-approve L5981. 
 
 
 
The Plan follows Medicare rules. Medicare rules say that L5981 is covered for enrollees with a functional level 
of 3 or above. 
 
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 for L5981. Our reviewer says that there is no 
documentation of a functional level of 3 or above to indicate L5981. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5981 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve L5981. 
 
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 drug testing provided to the enrollee on February 5, 2019 and 
billed under code G0483. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11.  Also, the laboratory results submitted indicate the 
specimen was collected on February 5, 2019 and received by the lab on February 7, 2019; therefore, the billed 
code cannot be verified. 
 
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 claim submitted cannot be paid 
as billed bases on issues with the POS code.  Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided to the enrollee on February 5, 2019 and billed under code G0483.