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

 
We decided that the Plan does not have to pre-approve therapeutic CGM test strips (Freestyle Lite). 
 
You asked the Plan to pre-approve therapeutic CGM test strips (Freestyle Lite). You say that you are appealing 
the denial of authorization for test strips. The Plan denied your request. The Plan says criteria has not been met 
and there is no clinical reasoning supporting an exception to the LifeScan exclusivity agreement. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for therapeutic 
CGM benefits. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of therapeutic CGM test strips have been met. Therefore, we decided 
that the Plan does not have to pre-approve therapeutic CGM test strips (Freestyle Lite).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87481 and 87798) provided on October 6, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services (87481 and 87798) provided on October 6, 2022.  
 
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 pre-approve 130 additional routine transportation trips. 
 
You asked the Plan to pre-approve 130 additional routine transportation trips. You say that you need 
transportation to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 130 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee saw this provider in 2019 and was 
unable to finish her treatment for cataracts due to the pandemic. The Plan denied your request. The Plan says 
the provider is out-of-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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 and procedure code 20206 billed for 
date of service September 21, 2022. 
 
You asked the Plan to pay for procedure code 77012 and procedure code 20206. You say that the member had 
multiple exams done on this date of service. The Plan denied your request. The Plan says payment for code 
77012 is bundled into payment for code 76942. Procedure code 20206 is a duplicate of a previously paid claim 
and was correctly denied.  
 
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, we have confirmed that code 77012 
is a column II code to column I code 76942. 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. Also, the file 
includes evidence that the items/services at issue were reimbursed by the Plan on November 02, 2022. 
Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that 
the billed items/services were provided twice on the same date. Therefore, we decided that the Plan does not 
have to pay for procedure code 77012 and procedure code 20206 billed for date of service September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the cardiology specialist services 
provided on October 25, 2022, and November 8, 2022. 
 
You asked the Plan to reduce the copayments for the specialist services. You say that these should have been 
charged as telehealth since you only consulted with the specialists over the phone. 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 $35 
copayment for in-network Level 1 specialist services.  
 
The services provided by the cardiology specialists do not fall within the telehealth benefit category. You have 
been asked to pay $32.43, which is less than the standard $35 copayment for the specialist services provided on 
October 25, 2022. You have also been asked to pay a $35 copayment for the specialist services provided on 
November 8, 2022. You have been asked to pay a total of $67.43 ($32.43 copayment + $35 copayment = 
$67.43). These items/services fall within the physician/practitioner 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 copayments for the cardiology specialist services provided on October 25, 2022, 
and November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on October 07, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for Medicare Part B prescription drugs provided on October 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that services were medically necessary. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 92960.  
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, we have confirmed that code 93010 
is a column II code to column I code 92960. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95861), nerve conduction 
studies (95913), and outpatient office visit (99204) provided on August 16, 2021. 
 
You asked the Plan to pay for the needle electromyography, nerve conduction studies, and outpatient office 
visit. You say that you were advised that the treating provider did not accept Medicare, but you could send in 
your own form for reimbursement. You also say that this procedure is very confusing, you are retired and on a 
limited income, and would like to be reimbursed for these services. The Plan denied your request. The Plan 
says you received these services from a provider who had opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the needle 
electromyography (95861), nerve conduction studies (95913), and outpatient office visit (99204) provided on 
August 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service November 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says that code J3490 is included in the global surgery period 
for procedure 64483. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that coincides with 
the drug documented in the medical records. Code J3490 is not an evaluation and management service. The 
drug is separately payable in this case. The Plan has not provided a Medicare rule that would indicate the drug 
should be included in the global surgery package. Based on this information, we decided that Medicare rules 
for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code J3490 billed for date of service November 17, 2022.  
 
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 the principal care management services provided on October 
14, 2022. 
 
You asked the Plan to pay for the principal care management services. You say that the enrollee was in a 
nursing home and could not choose a specific provider. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the principal care 
management services provided on October 14, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a percutaneous revascularization (37225). 
 
You asked the Plan to pre-approve a percutaneous revascularization. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
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 a percutaneous revascularization. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of Peripheral Arterial Disease of both lower extremities and 
has recurrent claudication in the right leg after bilateral iliac stents, known several bilateral superficial femoral 
artery (SFA) disease. He is complaint with medication and reports smoke cessation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous revascularization have been met. Therefore, we decided that the 
Plan has to pre-approve a percutaneous revascularization (37225).  
 
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 an urgent care visit provided on October 
21, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not think you should 
have to pay for this visit. 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 in and out-of-network urgent care visit. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the each in 
and out-of-network urgent care visit 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 urgent care visit provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740) and core buildup (D2950) for tooth #8 
and #9 provided on November 9, 2022, and November 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the dental procedures were 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct 
because the crowns and core buildup are not covered by the Plan. Also, it was verified the proper dental 
benefits were told to the enrollee. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
crowns (D2740) and core buildup (D2950) for tooth #8 and #9 provided on November 9, 2022, and November 
23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for intraoral - periapical first radiographic image (D0220) 
and resin - based composite -one surface, posterior (D2391) provided on November 28, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay more for dental services. You say that you want to be reimbursed for the total 
amount you paid for the billed services. The Plan denied your request. The Plan says enrollee's will be 
responsible for copays and coinsurance (that may be higher if they visit an out-of-network provider). 
 
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, the requested D0220 and D2391 are 
covered under this benefit, but your copayment or coinsurance may be higher when you visit an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay more for intraoral - periapical first 
radiographic image (D0220) and resin - based composite -one surface, posterior (D2391) provided on 
November 28, 2022, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee 
needs to get to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
100 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 254 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the lenses provided on August 18, 2022. 
 
You asked the Plan to pay for the frames and the lenses. You say that your eyeglasses were denied due to lack 
of a purchase receipt. You say you have provided it on a recent visit so that it may be included with the documents for the reimbursement request. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services authorization is obtained for out-of-network services. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network, and no authorization 
was obtained. Based on this information, we decided that the Plan's rules for coverage of the frames and the 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and the 
lenses provided on August 18, 2022.