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

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) (K0553) 
provided August 10, 2020. 
 
You asked the Plan to pay for the supplies. You say that the supplies are medically necessary. The Plan denied 
your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a Continuous Glucose Monitor and supplies 
to be covered, an enrollee must be insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The provided records show the enrollee is treated only once daily 
with insulin. Based on this information, we decided that Medicare rules for coverage of the supplies have not 
been met. Therefore, we decided that the Plan does not have to pay for supplies for a continuous glucose 
monitor (CGM) (K0553) provided August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided by from 
April 13, 2020, through August 13, 2020. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that the billing is a mistake. 
You say that you cannot pay this bill. The Plan denied your request. The Plan says the coinsurance applied 
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 each Medicare-covered item.  
 
You have been asked to pay a total of $97 for the oxygen concentrator.  
 
Date of Service Equipment Allowed Amount Coinsurance Member Liability 
April 13, 2020 Oxygen Concentrator $97 20% $19.40 
May 13, 2020 Oxygen Concentrator $97 20% $19.40 
June 13, 2020 Oxygen Concentrator $97 20% $19.40 
July 13, 2020 Oxygen Concentrator $97 20% $19.40 
August 13, 2020 Oxygen Concentrator $97 20% $19.40 
TOTAL:    $97 
 
  
 
 
The oxygen concentrator falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the oxygen concentrator provided by from 
April 13, 2020, through August 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of extracranial arteries 
(93880) performed on June 12, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of extracranial arteries. You say that you disagree 
with the cost-sharing amount. The Plan denied your request. The Plan says the correct copayment was 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 $150 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $150 copayment for an ultrasound of extracranial arteries. An ultrasound of 
extracranial arteries falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
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 of extracranial 
arteries (93880) performed on June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on 
August 25, 2020. 
 
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that you were told that you 
would not owe a copayment. 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received a diagnostic mammogram on August 25, 2020. The record shows that you had paid $0 toward the 
$750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$112.95.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic 
mammogram was received on August 25, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for a diagnostic mammogram provided on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided. 
 
You asked the Plan to pay for self-administered drugs. You say that you feel you should be reimbursed for 
these drugs because you could not return home to take them. The Plan denied your request. The Plan says the 
denial of payment for these drugs is correct, because these drugs are not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the direct skilled nursing services rendered from January 22, 
2020, to February 3, 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 the claim was billed with the incorrect revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that revenue code 055x must be billed with code 
G0300.  
 
We looked at the file and Medicare rules. The file shows that procedure code G0300 was not billed with the 
required 055x revenue code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the direct skilled 
nursing services rendered from January 22, 2020, to February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic x-ray rendered on July 23, 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 72190 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 72190 and 73502. Code 72190 is a column II code with a 
modifier indicator of 1 when billed with column I code 73502. Code 72190 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the pelvic 
x-ray rendered on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on July 17, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $9.80. The total amount you are being asked to pay is $1.96 ($9.80 x 20% = $1.96). An injection 
falls within the Medicare Part B prescription drugs/in-network 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 coinsurance for an injection provided by a participating provider on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the respiratory viral panel rendered on May 1, 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 that procedure code 87631 is non-covered. 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 procedure code 87631 is non-covered, however, the referenced Local Coverage Determination (LCD) L37764 is not valid for the state of Georgia where the testing was performed. The ruling LCD for the correct jurisdiction states that code 87631 is covered under specific conditions. The Plan has not provided any documentation to show that the services are not covered under these conditions. Therefore, we decided that the Plan has to pay for the respiratory viral panel rendered on May 1, 2020. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT Code E0667) and pneumatic compressor, segmental home model with calibrated 
gradient pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. There was no documentation of four-
week trial of conservative treatment including regular and compliant use of an appropriate compression 
bandage system or compression device. Also not documented was regular exercise, elevation of limbs, and 
manual lymphatic drainage for at least 30 minutes per day. Therefore, we decided that the Plan does not have to 
pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) 
and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services rendered on July 18, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes Q0992 and 
R0075. These codes have a PC/TC indicator of 3 and there is no separate PC payment. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the mobile x-ray services rendered on July 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 
22, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you weren't offered 
another option in regard to transportation. You say that the hospital should be responsible for the ambulance 
bill. The Plan denied your request. The Plan says the copayment applied 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 $150 
copayment for Medicare-covered one-way ground ambulance benefit. 
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transport provided on July 22, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination of the knee (73560) provided on May 30, 
2020. 
 
You asked the Plan to pay for the radiologic examination of the knee. You say that you would like 
reconsideration because the medical records did not indicate which side was x-rayed. The Plan denied your 
request. The Plan says that CPT code 73560 was reported without a required anatomical modifier. 
 
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 CPT code 73560 is supported in the record. Specifically, the clinical information does not indicate 
which knee was examined. Based on this information, we decided that Medicare rules for coverage of the 
radiologic examination of the knee have been met. Therefore, we decided that the Plan has to pay for the 
radiologic examination of the knee (73560) provided on May 30, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from April 22, 2020, to 
July 8, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from April 22, 2020, to July 8, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional mileage for your routine transportation benefit.
You asked the Plan to provide additional mileage for your routine transportation benefit. You say that you need
more mileage to get to your doctor appointments. The Plan denied your request. The Plan says the benefit is
limited to destinations within 75 miles of the pickup location.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation for 60 one way trips per calendar year within 75 miles of the
pickup location.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to provide additional mileage for your routine transportation benefit.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) provided on April 10, 2020. 
 
You asked the Plan to pay for hospital care. You say that this claim was previously paid and then retracted 
without a specific reason to why. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital care (99232) provided on April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new partial denture (D5226). 
 
You asked the Plan to pre-approve the partial denture. You say that the new denture is medically necessary 
because the existing one does not fit properly. The Plan denied your request. The Plan says the benefit for 
partial dentures has been exhausted at this time. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are only covered once 
every 5 years. The record shows a claim for a partial denture was paid on April 19, 2019. This exhausted the 
benefit for partial dentures. Therefore, we decided that the Plan does not have to pre-approve a new partial 
denture (D5226).
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the member does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. There is not a reasonable expectation that this individual will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. The member continues to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesn?t support that she would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the member would 
require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain her functional status.  The member is 
ambulating up to 50 feet with contact guard assistance and is at or near her prior level of function and could 
receive services at a lower level of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D testing (82306) provided on June 10, 2020. 
 
You asked the Plan to pay for Vitamin D testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Vitamin D testing is covered for the conditions 
listed above.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee has a covered condition. 
The testing at issue was billed with a diagnosis of type 2 diabetes mellitus with hyperglycemia. Based on this 
information, we decided that Medicare rules for coverage of Vitamin D testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Vitamin D testing (82306) provided on June 10, 2020.