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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
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 
Freestyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from May 29, 2019, 
through May 30, 2019, and billed with the diagnosis code E87.1 defined as Hypo-osmolality and hyponatremia. 
 You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports 
payment for the hospital care as originally billed. The Plan denied your request. The Plan says the billed 
diagnosis code E87.1, defined as Hypo-osmolality and hyponatremia, is not supported in the records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the diagnosis code, E87.1, defined as Hypo-
osmolality and hyponatremia. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital care as billed. Our reviewer says that the documentation does not support payment for the services as 
billed. Our physician reviewer found the review indicates that the 83-year-old female presented for surgery 
related to pituitary adenoma. On May 29, 2019, the patient underwent pituitary tumor removal, and 
documentation noted that the intraoperative and immediate postoperative course were uncomplicated. While 
documentation of hyponatremia is noted in one progress note on May 30, 2019, the clinical evidence did not 
support assignment of the diagnosis. In this case, only one serum sodium level was noted which was 133. There 
was no follow-up level found on review and no documentation of a specific treatment plan to address the 
condition. The review has determined that the documentation did not support the billing of diagnosis code 
E87.1.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from May 29, 2019, through May 30, 2019, and billed with the 
diagnosis code E87.1 defined as Hypo-osmolality and hyponatremia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on January 4, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $65 
copayment for an office visit.  
 
You have been asked to pay a $65 copayment for an office visit. An office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 office visit on January 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second ultrasonic guidance for needle placement (76942) 
provided on December 17, 2021. 
 
You asked the Plan to pay for the second ultrasonic guidance for needle placement. You say that the 
documentation does support the services billed and we should be properly reimbursed. The Plan denied your 
request. The Plan says the documentation received does not support that two separate ultrasonic guidances 
were performed.  
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 76942 is Ultrasonic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the second ultrasonic guidance for needle placement. Our 
reviewer says that the second ultrasonic guidance for needle placement is not supported in the medical records. 
Our reviewer found detailed documentation is not evident regarding an ultrasound being used at any other time 
during the procedure. Our reviewer also found that the records do not support that ultrasonic guidance for 
needle placement was rendered twice in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the second ultrasonic guidance for needle placement have not been met. 
Therefore, we decided that the Plan does not have to pay for a second ultrasonic guidance for needle placement 
(76942) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve medical and radiation oncology services to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve out-of-network oncology services. You say that it is ridiculous to have to 
drive two and a half hours for care. The Plan denied your request. The Plan says that rules for coverage for out-
of-network care have not been met. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers 
located within reasonable distance and travel time from your home who can provide oncology services. Under 
Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the 
Plan has to pre-approve medical and radiation oncology services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis procedures. 
 
You asked the Plan to pre-approve dialysis procedures. You say that the current facility is very good and you 
do not want to explore other places. The Plan denied your request. The Plan says you must receive care from a 
network provider. 
 
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 
dialysis procedures.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on November 18, 2021, to 
December 15, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically 
necessary. The Plan denied your request. The Plan says that the criteria for an inpatient admission are not met 
in this case. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department on November 18, 2021, with weakness and 
abdominal pain. He reported having no food or water for three days. Creatinine was 2.72, and he was admitted 
for dehydration. Over the next two days, creatinine increased to 2.95 then to 3.3 despite rehydration. The 
record show that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on November 18, 2021, to December 15, 2021.  
 
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Cardiovascular stress test, Technetium, 
and injection on November 30, 2021. 
 You asked the Plan to waive the cost-sharing for Part B drug, medical supply, and non-radiological diagnostic 
services. You say that you do not agree with the amount being charged. The Plan denied your request. The Plan 
says the cos-sharing you are being charged is correct. 
 
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 each Medicare-covered Part B drugs, 20% coinsurance for each Medicare-covered medical 
supply, and $20 copayment for Medicare-covered non-radiological diagnostic services. 
 
For service (Cardiovascular stress test) the provider billed the plan in the amount of $215.60. The allowed 
amount is $58.52. The enrollee is responsible for a $20 copayment for Medicare-covered non-radiological 
diagnostic services. The plan paid $38.52 and $20.00 applied as the members copayment. 
 
For service (Technetium) the provider billed the plan in the amount of $400.00. The allowed amount is 
$222.20. The enrollee is responsible for a 20% coinsurance for each Medicare-covered medical supply. 20% of 
the $222.20 allowed amount is $44.44. The plan paid $177.76 and $44.44 applied as the enrollees coinsurance. 
 
For service (Injection) the provider billed the plan in the amount of $260.00. The allowed amount is $238.20. 
The enrollee is responsible for a 20% coinsurance for each Medicare-covered Part B drug. 20% of the $238.20 
allowed amount is $47.64. The plan paid $190.56 and $47.64 applied as the enrollees coinsurance. Therefore, 
your total cost-sharing amount is $112.08.  
 
You have been asked to pay a 20% coinsurance for each Medicare-covered Part B drugs, 20% coinsurance for 
each Medicare-covered medical supply, and $20 copayment for Medicare-covered non-radiological diagnostic 
services. Part B drug, medical supply, and non-radiological diagnostic services falls within the Medicare Part B 
Prescription Drugs, and 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 cost-sharing for Cardiovascular stress test, Technetium, and injection on 
November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport on December 02, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. 
 
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 $200 
copay per one-way trip (includes ground and air transport) for each Medicare-covered ambulance service. 
Covered ambulance services include fixed wing, rotary wing and ground ambulance services, to the nearest 
appropriate facility that can provide care if they are furnished to a member whose medical condition is such 
that other means of transportation could endanger the persons health or if authorized by the plan. 
 
 
  
You have been asked to pay a $200 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance service 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 ambulance transport 
on December 02, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of lumbar spine (72131), CT 
of cervical spine (72125), CT of thoracic spine (72128), and CT of head/brain during emergency room visit 
(70450) provided on December 10, 2021. 
 
 
 
 You asked the Plan to pay for the radiology services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 the computed tomography (CT) of lumbar spine (72131), CT 
of cervical spine (72125), CT of thoracic spine (72128), and CT of head/brain during emergency room visit 
(70450) provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service April 29, 
2020. 
 
You asked the Plan to pay for procedure code 99213. You say that these services are payable. The Plan denied 
your request. The Plan says you did not file this claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for procedure code 99213 was not filed until October 28, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for procedure code 99213 billed for date of service April 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0463 billed for date of service February 22, 2022. 
 
You asked the Plan to pay for procedure code G0463. You say that this is a payable service. The Plan denied 
your request. The Plan says that this service was already paid. 
 
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. Specifically, the Plan's sole denial rationale is that this service was already paid.  
However, the 'proof' that the Plan submitted in support of its denial does not confirm the Plan's assertion. The 
claim that the Plan paid for this same date of service was for a completely different provider, a different 
provider type, a different procedure code, and a different amount. None of these things match with the Plan's 
'duplicate' argument. The Plan has provided no other proof or support for its denial. Based on this lack of 
information, we find that the Plan's denial is not appropriate. Therefore, we decided that the Plan has to pay for 
procedure code G0463 billed for date of service February 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for foot orthotics have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. In this case, you are requesting a replacement for foot orthotics 
received in July 2021. Therefore, the requested replacement is for items that has not outlasted their reasonable 
useful lifetime. Based on this information, we decided that Medicare rules for coverage of foot orthotics have 
not been met. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on November 
11, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that amphetamines were detected on the screening urine test and this finding was not consistent with 
prescription medications or history and expected results. Rationale for the other drug classes tested on the 
definitive drug testing was not provided.  
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the definitive drug testing (G0483) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0270) and the intraoral-periapical first 
radiographic image (D0220) provided on January 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
these services. 
 
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.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plan contract says that one bitewing x-ray set 
and one periapical x-ray is covered per year. You previously received these services on January 7, 2022; 
therefore, you have exceeded the allowable benefit for these services.  Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) and the intraoral-
periapical first radiographic image (D0220) provided on January 28, 2022.