Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on December 14, 
2021. 
 
You asked the Plan to pre-approve the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says that the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that ferritin, iron and either iron binding capacity or 
transferrin are useful in the differential diagnosis of iron deficiency, anemia, and for iron overload conditions. 
 
 
 
 
 
 
 
 
 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the enrollee has a history of erythrocytosis. The enrollee has a 
less than fifty year history of nicotine abuse, with at least a ten year history of erythrocytosis. In a review of the 
patient's laboratory studies in the Bassett system, erythrocytosis was noted in September 2011, with a 
hemoglobin of 18.5 on 9/1/11. Patient has had intermittent health care due to multiple incarcerations. The 
patient has been referred for further hematological evaluation on 10/08/2021. The laboratory studies were 
performed showed a hemoglobin of 19.6, hematocrit of 57.1, normal erythropoietin and carboxyhemoglobin. 
The obtained serum ferritin level was medically necessary and reasonable. The review indicates that the 
enrollee has an appropriate diagnosis for this request. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve laboratory services provided to the enrollee on December 14, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 150mg Ofev Capsules. 
 
You asked the Plan to pre-approve the Ofev. You say that you would like reconsideration because the Ofev is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part 
B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 150mg Ofev Capsules.  
 
Benefits for the Ofev may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a glucose monitor (95250) provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for the glucose monitor. You say that the services should be 
covered as you disagree with the charges and would have never gotten them if you knew it was $30. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $30 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $30 copayment for a glucose monitor. Glucose monitoring 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 a glucose monitor (95250) provided on December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40mg DR esomeprazole magnesium capsules. 
 
You asked the Plan to pre-approve the esomeprazole magnesium. You say that you would like reconsideration 
because the esomeprazole magnesium is medically necessary. The Plan denied your request. The Plan says this 
drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 40mg DR esomeprazole 
magnesium capsules.  
 Benefits for the esomeprazole magnesium may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on December 15, 
2021.  
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 pain management 
services rendered on December 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Synthroid is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid.  
 Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 treat with insulin three or more times per day or use an insulin pump. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgery treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve vascular surgery. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist. 
 
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 
vascular surgery treatment to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 24, 2021. 
 You asked the Plan to pay for the ambulance services. You say that the patient was not on hospice until the 
transport was complete because the hospice nurse was waiting at the residence to sign the paperwork. The Plan 
denied your request. The Plan says Original Medicare is responsible for this claim because the member was on 
hospice on the date of service. 
 
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 also say that the hospice 
election is effective on the date of election.  That means that any services that occur on the date of election are 
considered to have taken place during the hospice election, even if the signing of the election paperwork occurs 
later in the day than the services themselves. 
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa 75mg tablets. 
 
You asked the Plan to pre-approve Gemtesa. You say that Gemtesa is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa 75mg tablets.  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10060 billed for date of service November 
19, 2021. 
 
You asked the Plan to pay for procedure code 10060. You say that this service was not part of the global period 
due to complications. The Plan denied your request. The Plan says it agrees that this service was unrelated to 
the cholecystectomy surgery the member had.  However, you did not bill with an appropriate modifier to show 
that this was an unrelated procedure. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that modifier 79 should be appended when an 
unrelated procedure is performed by the same surgeon within the global period of another surgery. If the 
subsequent procedure is related to the initial surgery and required a return to the operating room, modifier 78 
should be appended. In this case, the Plan agrees that procedure code 10060 is unrelated to the first surgery.  
However, you have not appended an appropriate modifier to the claim that would permit separate payment for 
this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 10060 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 10060 billed for date of service November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the laboratory service (88305) 
rendered by the out-of-network (OON) provider on November 2, 2021. 
 
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 the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99204) and the laboratory service (88305) rendered by the out-of-
network (OON) provider on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography provided to the enrollee on November 
15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 92250 remains 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 92250 is "Fundus photography with interpretation and 
report." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not include an 
interpretation and report for this procedure. 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for fundus photography provided to the enrollee on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38525-59-LT provided on September 15, 
2021. 
 
You asked the Plan to pay for procedure code 38525-59-LT. You say that you have provided medical records 
to support payment of this code. The Plan denied your request. The Plan says procedure code 38525-59-LT is 
considered inclusive to the other procedures performed on the same day (19303-LT and 38745-59-LT). The 59 
modifier is not supported in the record. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 38525-59-LT Our reviewer 
says that payment for this code is not supported in the medical record.  Our physician reviewer found that the operative report describes a complete mastectomy, with sentinel lymph 
node biopsy. This procedure would be inclusive to a complete mastectomy, as these procedures were 
performed on the same side. Sentinel lymph node biopsy is separately reportable when performed prior to a 
localized excision of breast or a mastectomy without lymphadenectomy. However, sentinel lymph node biopsy 
is not separately reportable with a mastectomy procedure that includes lymphadenectomy in the anatomic area 
of the sentinel lymph node biopsy. Open biopsy or excision of sentinel lymph node(s) should be reported as 
follows: axillary (codes 38500 or 38525), deep cervical (code 38510), internal mammary (code 38530). Code 
38740 (Axillary lymphadenectomy; superficial) should not be reported for a sentinel lymph node biopsy. 
Sentinel lymph node biopsy of superficial axillary lymph node(s) is correctly reported as code 38500 (Biopsy 
or excision of lymph node(s), open, superficial) which includes the removal of one or more discretely identified 
superficial lymph nodes. By contrast, a superficial axillary lymphadenectomy (code 38740) requires removal of 
all superficial axillary adipose tissue with all lymph nodes in this adipose tissue" 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 38525-59-LT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 38525-59-LT provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
23, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided records to support 
payment of this claim. The Plan denied your request. The Plan says no separate payment is made for this code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve the personal care services. You say that you would like reconsideration 
because you have health issues and need someone to help around the house. The Plan denied your request. The 
Plan says custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that your left arm needs acupuncture to get rid of the 
numbness. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because acupuncture is not covered by Medicare or the Plan for your condition. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture is not being requested for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temporomandibular Joint (TMJ) therapy received on 
November 17, 2021. 
 
You asked the Plan to pre-approve the services. You say that the treatment worked. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
 
 
 We looked the file and Medicare rules. A diagnosis of TMJ alone is not enough to cover these services. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Temporomandibular Joint (TMJ) therapy received on 
November 17, 2021.