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

 
We decided that the Plan does not have to pay for codes J3490 and 77003 provided on December 9, 2022. 
 
You asked the Plan to pay for codes J3490 and 77003. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 J3490 is not supported in the medical record. Specifically, this code was billed on the 
same date of service as surgery procedure 64490. This means this service is included in the global surgical 
period of the surgery and is not separately payable. 
 
In this case, we have confirmed that code 77003 is a column II code to column I code 64490. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
Based on this information, we decided that Medicare rules for coverage of codes J3490 and 77003 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes J3490 and 77003 provided on 
December 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided by an 
in-network provider from October 5, 2022, to October 9, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that the enrollee should be 
responsible for a lower 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment per day, for days 1-6, for in-network Medicare-covered inpatient hospital stays. 
 
 The enrollee has been asked to pay a $1180 copayment for the inpatient hospital stay ($295 x 4 days = $1180). 
This item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to reduce the copayment for the inpatient hospital stay provided by an in-network provider from October 
5, 2022, to October 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G7 continuous glucose monitor system. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee is not on 
insulin and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
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, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G7 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dexcom G7 continuous glucose monitor 
system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam provided on May 19, 2022. 
 
You asked the Plan to pay for an x-ray exam. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 18, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for an x-ray exam provided on 
May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 16, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the services were provided after the enrollee 
revoked hospice on September 6, 2022. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on September 16, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bunionectomy. 
 
You asked the Plan to pre-approve bunionectomy. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bunionectomy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the enrollee is noted to have a moderate to severe bunion deformity on the left side 
that is painful. The requested scarf bunionectomy meets the Medicare coverage criteria noted above and should 
be considered medically reasonable and necessary for the treatment of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bunionectomy have been met. Therefore, we decided that the Plan has to pre-
approve bunionectomy.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 12, 2022. 
 You asked the Plan to pay for ambulance services. You say that the claim needs to be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 ambulance services provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 5, 
2022, to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 5, 2022, to December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on 
December 14, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you think that the 
copayment should be lower. 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 $50 
copayment for each Medicare-covered urgent care facility visit. 
 
 You have been asked to pay a $40 copayment for the urgent care visit because the Plan is only holding you 
responsible for this amount, which is less than the $50 copayment. This item/service falls within the urgently 
needed 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 reduce the copayment for the urgent care visit 
provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestlye Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestlye Libre 2 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) provided on December 10, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that the enrollee needs this 
item. The Plan denied your request. The Plan says the date of service does not match the delivery date, 
shipping date or the date the label was created. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor 
(CGM) (K0553) provided on December 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crown - porcelain/ceramic (D2740) Tooth #19. 
 
You asked the Plan to pre-approve dental services. You say that you are appealing the denial of the requested 
service. The Plan denied your request. The Plan says that your tooth has too little bone in the middle of the 
roots. Your tooth would need to have more bone in the middle of the roots to be allowed. 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our physician reviewer 
found tooth #19 has a large restoration comprising more than 50% of the coronal structure. The bone support 
appears adequate. A crown restoration is medically reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have been met. Therefore, we decided that the Plan has to pre-
approve crown - porcelain/ceramic (D2740) Tooth #19.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the eyeglasses to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the eyeglasses. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says that the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not send the Evidence of Coverage. This means we are unable to 
determine if the benefit was applied correctly. Therefore, we decided that the Plan has to pre-approve the 
eyeglasses to be provided by an out-of-network provider. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. You say the LTACH is the safest and most efficient care level based on the 
enrollee's current needs. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on December 8, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an MRI with contrast provided on 
November 23, 2022. 
 
You asked the Plan to waive the cost share for an MRI with contrast. You say that you were unaware of the 
responsible cost share and do not feel you should owe anything. 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 of the allowed amount for intravenous, subcutaneous, and biological Part B drugs and a $100 
copayment for an MRI.  
 
You have been asked to pay a total cost share of $107.91 for an MRI with contrast. The total includes a $7.91 
coinsurance for the injection prescription drug ($39.56 allowed x 20% = $7.91) and a $100 copayment for an 
MRI. The injection prescription drug falls within the Medicare Part B Prescription Drug benefit category. The 
MRI falls within the Outpatient 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 
cost share for an MRI with contrast provided on November 23, 2022.  
 
Your complaint about not being aware of the cost share for the MRI is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical access to an implant body (second stage implant surgery) 
(D6011) five units. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services as part of your 
treatment plan. The Plan denied your request. The Plan says that the request is denied because the medical plan 
only gives two per year. 
 
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 Evidence of Coverage (EOC) states crowns on implants are covered one (1) 
per tooth every five (5) years with appropriate justification. Implant services will only be covered when 
performed by a certified provider. All abutments are covered one (1) per tooth per life. Therefore, we decided 
that the Plan has to pre-approve surgical access to an implant body (second stage implant surgery) (D6011) 5 
units.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 5, 2022. 
 
You asked the Plan to pay for subsequent nursing facility. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 subsequent nursing facility care provided on July 5, 2022.