Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your father 
fell, and the emergency medical technicians (EMTs) were called to help him get up. You also say that he was 
not transported to the hospital because the EMTs said he did not need to go. The Plan denied your request. The 
Plan says it was confirmed, through the provider, that the enrollee chose not to be transported by the 
ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The records show that the enrollee said they did not want to go to the hospital. Therefore, we decided that the 
Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on 
August 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urgent care visits and COVID-19 tests 
provided from April 20, 2022, to June 15, 2022. 
 
You asked the Plan to waive the copayments for the urgent care visits and COVID-19 tests. You say that these 
visits were strictly for COVID-19 testing. 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 under the Urgently needed services benefit 
category. 
 
 
  You have been asked to pay $50 copayments for the urgent care visits and COVID-19 tests. This items/services 
fall 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 waive the copayments 
for the urgent care visits and COVID-19 tests provided from April 20, 2022, to June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator TENS supplies (A4595) provided on 
September 9, 2022. 
 
You asked the Plan to pay for electrical stimulator TENS supplies. You say that this claim was billed in 
accordance with policy. The Plan denied your request. The Plan says there is no evidence to support the 
ordering physician has ordered the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a written 
order/prescription from the treating practitioner with the quantity to be dispensed. 
 
The record does not contain a valid written order/prescription from the treating practitioner. Specifically, the 
prescription form does not specify the quantity of supplies to be dispensed with the order. Based on this 
information, we decided that Medicare rules for coverage of electrical stimulator TENS supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for electrical stimulator TENS supplies (A4595) 
provided on September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the continuous positive airway pressure 
(CPAP) equipment provided on October 13, 2022. 
 
You asked the Plan to waive the cost-sharing for the continuous positive airway pressure (CPAP) equipment. 
You say that this cost-sharing is difficult for you to pay. 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 20% 
coinsurance of the total cost for Medicare-covered durable medical equipment, which includes oxygen 
equipment. 
 
 
 
 You have been asked to pay a cost-share of $8.98 for the continuous positive airway pressure (CPAP) 
equipment ($44.90 x .20 = $8.98). This item/service 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 cost-sharing for the continuous positive 
airway pressure (CPAP) equipment provided on October 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like a reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and your needs can be met at an alternate level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit provided on September 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a hospital visit. You say that this was medically necessary and should be 
covered. We got a referral. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a hospital visit provided on September 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for COVID-19 test kits purchased on July 6, 2022. 
 
You asked the Plan to pay more for COVID-19 test kits. You say that you went to purchase COVID-19 test kits 
and were informed the pharmacy did not have any in stock so you were instructed to purchase them out-of-
network and file for reimbursement afterward. The Plan denied your request. The Plan says they denied the 
enrollees request for an additional reimbursement of $42 because this amount is above $12 per test which 
exceeds the allowance in accordance with the Federal mandate. 
 
The Plan must follow Medicare rules. Medicare rules say that enrollees cannot submit a claim for these tests to 
Medicare or their MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to pay 
more for COVID-19 test kits purchased on July 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 22, 2022, to 
April 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of August 24, 2021, was received on April 29, 2022. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from March 22, 2022, to April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies (A4239, 
E2103). 
 
You asked the Plan to pay for the CGM and supplies. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies 
(A4239, E2103).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36000 and 94760 billed for date of service 
December 28, 2021. 
 
You asked the Plan to pay for procedure codes 36000 and 94760. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 36000 and 94760 are considered 
bundled and 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 procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Procedure code 94760 has a status indicator of T on the 
Schedule. This means that procedure code 94760 is bundled into the physician services billed on the same date 
by the same provider for which payment is made. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 36000 and 94760 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36000 and 94760 billed for date of service December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown. 
 
You asked the Plan to pre-approve a porcelain crown. You say that this is medically necessary. The Plan 
denied your request. The Plan says we cannot determine if the crown is medically necessary without medical 
records. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a porcelain crown have been met. missing dental x-rays. Specifically, medical records were not submitted to determine if the crown is necessary. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that it is necessary for you to get a new pair of 
orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial and they are necessary. The Plan denied your request. The Plan says the services denied correctly as they 
do not meet the clinical requirements to be approved. 
 
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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee was started on tolterodine in March 2022, though for how long the enrollee took the medication and 
what the results were are unclear. On January 6, 2023, the enrollee is noted to have recently started Myrbetriq, 
with inadequate time to assess its effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy of a premolar tooth (D3320) provided on 
June 23, 2022. 
 
You asked the Plan to pay for endodontic therapy of a premolar tooth (D3320). You say that you were unaware 
that the benefits were not covered under your policy. The Plan denied your request. The Plan says this is not a 
covered service. 
 
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 
endodontic therapy of a premolar tooth (D3320) provided on June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 37229, 75710, and 75625 for 
September 27, 2022. 
 
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 supported. 
 
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 37229 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed. The definition of code 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. The definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. We find that CPT codes 37229, 75710, and 75625 are not supported in the medical record. Specifically, the 
operative report does not contain documentation of an open or percutaneous endovascular revascularization of 
a unilateral tibial or peroneal artery to support code 37229. There is no documentation of radiological 
supervision and interpretation of a unilateral extremity angiography to support code 75710. There is no 
documentation of radiological supervision and interpretation of an abdominal aortography by serialography to 
support code 75625. 
 
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 services billed with codes 37229, 75710, and 
75625 for September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13122 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 13122. You say that you would like the plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 13122 is bundled into 
payment for code 20103. 
 
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 13122 
is a column II code to column I code 20103. 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 13122 billed for date of service June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gloves, non-sterile. 
 
You asked the Plan to pre-approve gloves, non-sterile. You say that you would like reconsideration because the 
requested gloves, non-sterile are medically necessary. The Plan denied your request. The Plan says the 
requested gloves, non-sterile are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve gloves, non-sterile.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing, and gingival 
irrigation (D4341, D4921). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 25, 2021. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing, and 
gingival irrigation (D4341, D4921).