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

 
We decided that the Plan does not have to pre-approve the Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 does not show that you are using 3 or more 
insulin shots per day or be on an insulin pump or that you require frequent changes to your insulin dosing. 
Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection services. 
 
You asked the Plan to pre-approve SI joint injection services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested SI joint injection services are 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 pre-approve SI joint injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of tenderness of the SI joint and 
no mention of SI provocative testing being completed with positive findings. The clinical value and 
effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. The review has determined that the enrollee does not 
have a diagnosis/condition that meets the criteria for the requested services. The requested sacroiliac joint 
injection is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac (SI) joint injection services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the laboratory services are the 
responsibility of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for magnetic resonance imaging (MRI) of the 
pelvis and abdomen provided on January 13, 2022, and January 14, 2022. 
 
You asked the Plan to waive the copayments for the MRI's. You say that you had both procedures the same 
day. You say that you cannot afford the copayments. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $75 
copayment for each MRI at a free-standing provider.  
 
The file shows that you had one MRI on each day. Therefore, you have been asked to pay a $75 copayment for 
each of the MRI's, for a total of $150. The MRI's fall 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 copayments for magnetic 
resonance imaging (MRI) of the pelvis and abdomen provided on January 13, 2022, and January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on November 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on October 9, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says the 
claim was untimely and the submission did not meet the exception criteria guidelines outlined in Medicare 
Claims Processing Manual Chapter 1 Sections 70.1 and 70.4. 
 
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 an emergency department visit was not filed until March 7, 2022. 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 an emergency department visit provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid battery rendered on December 21, 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 procedure code V5266 is not covered. 
 
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 V5266 has a status indicator of N on the Physician Fee Schedule. This means that CPT 
code V5266 is not covered. 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 hearing aid battery 
rendered on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection on March 18, 2022. 
 
You asked the Plan to waive the copayment for an injection on March 18, 2022. You say that you did not know 
this procedure would be considered outpatient surgery. The Plan denied your request. The Plan says you must 
pay a $290 copayment for each in-network ambulatory surgical center visit. 
 
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 $290 
copayment for Outpatient Surgery Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
 
 
 
 
 You have been asked to pay a $290 copayment for an injection on March 18, 2022. An injection 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 an injection on March 18, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an injection of rituximab and cataract 
surgery provided on November 1, 2021 and December 8, 2021. 
 
You asked the Plan to waive the cost-sharing for Part B drug and cataract surgery. You say that you did not pay 
for the same services before. The Plan denied your request. The Plan says the cost-sharing amounts you are 
being charged are 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 20% 
coinsurance for Part B drug and $250 copayment for cataract surgery. The allowed amount of the rituximab is 
$8,693.70, resulting in a coinsurance amount of $1,738.74. Therefore your total cost-sharing amount is 
$1,988.74.  
You have been asked to pay 20% coinsurance for Part B drug and $250 copayment for cataract surgery. Part B 
drug and cataract surgery falls within the "Medicare Part B Prescription Drugs" and "Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit 
categories. 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 an injection of rituximab and cataract 
surgery provided on November 1, 2021 and December 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered from January 
13, 2022, to February 23, 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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a Licensed Professional Counselor (LPC) is not 
eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. The file shows that the services were performed by a LPC. Therefore, 
we decided that the Plan does not have to pay for the outpatient mental health services rendered from January 
13, 2022, to February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 shows that the enrollee is only taking insulin 
once daily. Based on this information, we decided that Medicare rules for coverage of the sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 Sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on January 11, 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 covered. 
 
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 pay for the self-administered drugs 
rendered on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the Freestyle Libre is necessary. The Plan 
denied your request. The Plan says the Medicare rules have 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 does not show that the enrollee is insulin-treated 
with multiple (three or more) injections of insulin a day. Based on this information, we decided that Medicare 
rules for coverage of the Freestyle Libre have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 3, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the procedure 
code is inconsistent with the modifier used. 
 
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 00812 was billed with a -PT modifier, indicating a colorectal screening test led to a 
diagnostic procedure. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services 
are reported with CPT code 00811 and with the -PT modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on February 
3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 16, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home health physical therapy visits for 
the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled physical therapist to make 
more home visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that based on the medical records provided, there is no documentation that additional skilled therapy services 
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the patient's level of function and/or 
prevent deterioration. As of 7/20/22, the enrollee was walking 80 feet with a rolling walker with stand-by 
assistance and was contact guard assist for transfers. The provided records do not document any acute or 
unstable medical conditions or changes in medication or treatment which would necessitate any further skilled 
therapy visits beyond what have already been approved. No medical notes from the enrollees treating 
physician are provided documenting a need for additional skilled therapy services. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home health physical therapy visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spinal surgery allograft (20930) and autograft (20936) 
provided on February 12, 2022. 
 
You asked the Plan to pay for a spinal surgery allograft and autograft. You say that you have provided medical 
records to support the services billed. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 20930 and 20936 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of a spinal surgery allograft and autograft have not been met. Therefore, we 
decided that the Plan does not have to pay for a spinal surgery allograft (20930) and autograft (20936) provided 
on February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 services provided on March 11, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology (code 88305) provided on  
October 27, 2021. 
 
You asked the Plan to pay for surgical pathology. The Plan denied your request. The Plan says the Plan cannot 
determine how the member came to the servicing provider or if the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 surgical pathology (code 88305) provided on October 27, 2021 have been met. Therefore, we decided that the Plan does not have to pay for 
surgical pathology (code 88305) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit option. 
 
You asked the Plan to pre-approve the transit option. You say that the transit option is necessary. The Plan 
denied your request. The Plan says the transit option does not serve a medical purpose and is not appropriate 
for use in the home and it is excluded from coverage. 
 
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. Furthermore, DME outside of the home is not covered. Therefore, we decided that the Plan does not have to pre-approve the 
transit option.