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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM and supplies. You say that the requested 
CGM and supplies is medically necessary due to other general symptoms and signs. The Plan denied your 
request. The Plan says the enrollee does not meet coverage criteria for the requested CGM and supplies. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day continuous glucose monitor (CGM) and supplies (K0553, K0554).
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 June 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance crew came to your home and checked you out, but someone else took you to the hospital after it was 
determined you needed attention but did not need the ambulance. You also say that you feel this emergency 
care service should be covered by the Plan. The Plan denied your request. The Plan says you felt unwell and 
were evaluated, but you declined transport to the emergency room. 
 
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 June 30, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says a myoelectric orthosis is not medically reasonable and medically necessary 
for the enrollee in this case. The MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. 
 
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 a MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. The MyoPro Orthosis is still being studied to establish clinical effectiveness and long-term safety 
of the device. 
 
 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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) 
purchased on January 7, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the deluxe frames and progressive lenses. You say that this is the first time you 
purchased eyewear through the Plan for this calendar year. The Plan denied your request. The Plan says the 
request for reimbursement for $90 for eyewear has already been processed. The Plan also says that two 
payments for the same request cannot be processed, and you have already exceeded the benefit for this year. 
 
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 up to $90 per calendar year if you use a non-participating provider. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that this was the second request for the 
same purchase. A payment was sent to you on January 26, 2022, and the check was cashed. Based on this 
information, we decided that the Plan's rules for coverage of the deluxe frames and progressive lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and 
progressive lenses (V2781) purchased on January 7, 2022, from an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87496, 87532) provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 87496, & 87532 are not supported in the medical record. Specifically, the record did 
not include a lab order for these tests. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for lab services (87496, 87532) provided on 
December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the device is 
medically necessary. The Plan denied your request. The Plan says the medical records do not show the enrollee 
has lymphedema of the abdomen/trunk area or lymphedema of the belly/trunk. The enrollee does not meet 
coverage criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) 
device (E0730), provided on June 12, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says a valid proof of delivery was not submitted. 
 
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 provided in this case. The date of service does not match 
the date on the packing or delivery slips. 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 
Transcutaneous Electrical Nerve Stimulation (TENS) device (E0730), provided on June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation treatment services provided on May 9, 2022, 
May 17, 2022, May 19, 2022, May 24, 2022, and June 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiation treatment services. You say that you had an authorization for the 
dates of services, and you would like the claims paid. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization for the 
dates of service. Also, the service rendered was not urgent or emergent. 
 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 the radiation treatment services provided on May 
9, 2022, May 17, 2022, May 19, 2022, May 24, 2022, and June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received from providers who 
have performed biopsies. The Plan denied your request. The Plan says the specimen was obtained in an office 
setting. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on May 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology therapy provided on May 03, 
2022, to June 06, 2022. 
 
You asked the Plan to waive the copayment for radiology therapy. You say that you cannot afford to pay the 
copayment for these visits. 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for radiology therapy. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for radiology therapy provided on May 03, 2022, to June 06, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 77067. We decided that the Plan does not have to pay 
for procedure code 77063.  
 
You asked the Plan to pay for the diagnostic imaging services provided on April 25, 2022. You say that the 
codes were not bundled with any other procedures. The Plan says that a PTP edit exists between 77066-77067 
and 77063. 
 
We decided that the Plan has to pay for procedure code 77067.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The file shows that there are no PTP code edits for code pair 77067 and 77063. Based on this information, we 
decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for 
procedure code 77067 billed for date of service April 25, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 77063. 
 
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 77063 is a column II code to column I code 77066. This code has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, we find that the 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77063 billed for date of service April 25, 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 waive the coinsurance for durable medical equipment (DME) 
provided on June 26, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you do not want the equipment. 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 for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount is $461.55. The total 
amount you are being asked to pay is $92.31 ($461.55 x 20% = $92.31). 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 durable medical equipment (DME) provided on June 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00563 provided on May 26, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 00563 is anesthesia for procedures on heart, pericardial 
sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest. 
 
We find that CPT code 00563 is not supported in the medical record. Specifically, the medical records 
submitted do not include an anesthesia report. Without this documentation, the billed service, units, and 
modifier cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 00563 provided on May 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you cannot afford to pay this amount. 
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 $370 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $370 copayment for a biopsy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a biopsy provided on June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the office was unaware that an authorization was 
needed due to being an OON provider. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no approved authorization. 
  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 an office visit provided on May 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on July 13, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. 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 an office visit. The allowed amount for the services was less than the enrollees copayment, 
therefore the enrollee is responsible for the lesser amount, $22.50. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on July 22, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the referring provider sent the 
specimens to your laboratory to process, and you would like the claim to be paid. The Plan denied your request. 
The Plan says the rendering and referring providers are both OON providers and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the surgical pathology services provided on July 
22, 2022, by an out-of-network (OON) provider.