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

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
(K0554) and supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not use insulin with at least three daily injections and 
requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 and requires 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 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service March 4, 
2021. 
 
You asked the Plan to pay for the billed services. You say that the lab is in compliance with the guidelines for 
drug testing. The Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that the 
testing of 22 or more drug classes were ordered or tested based on clinical history or risk assessment. Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 billed for date of 
service March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 25, 
2022, to June 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider relies on the facility where the 
enrollee resides to obtain necessary authorizations. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 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 subsequent nursing facility care provided on June 25, 2022, 
to June 29, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that EMS informed you the nearest emergency 
room was packed and not accepting any ambulances. You also say that they informed you it would be better to 
have a friend take you to another hospital. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
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 May 29, 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 services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #14. 
 
You asked the Plan to pre-approve the dental service. You say that you have been getting infections. The Plan 
denied your request. The Plan says that there is no additional information to show that the crown is being 
requested for any other reason than to close a gap. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the replacement crown on tooth #14 to close the open contact is medically reasonable and necessary. Our 
physician reviewer found that the documentation provided meets the criteria for coverage for a replacement 
crown (D2750) for tooth #14 to close the open contact between teeth #'s 14 and 15 and correct the periodontal 
defect. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #14.  
 
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 pay for the disposable drug delivery system (A4305) and infusion 
supplies (A4223), provided on May 23, 2022, through May 25, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and infusion supplies. You say that the items 
are medically necessary. The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery 
systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system and infusion supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies (A4223), provided on May 23, 2022, through May 25, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the screening colonoscopy (G0105) provided on September 12, 2022. 
 
You asked the Plan to pay for the screening colonoscopy (G0105). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the screening colonoscopy (G0105) by a contract provider. The file does not show that 
the Plan provided notice that the screening colonoscopy (G0105) would not be covered. Under Medicare rules, 
this means the screening colonoscopy (G0105) is considered approved by the Plan. Therefore, we decided that 
the Plan has to pay for the screening colonoscopy (G0105) provided on September 12, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
(TDAP) vaccine (90715) and immunization administration (90471) provided on February 17, 2022. 
 
You asked the Plan to pay for the TDAP vaccine and administration. You say that the summary of benefits the 
enrollee received stated they would not pay any copays for visits with in-network providers, but they are being 
billed a copay which was not paid for by the Plan. The Plan denied your request. The Plan says that this service 
was not billed with an appropriate diagnosis. 
 
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. The Plan denied this service stating it is not covered when provided for 
preventive services. However, no medical records were requested or provided by the Plan to support this 
denial. Therefore, we decided that the Plan has to pay for the Tetanus, Diphtheria Toxoids and Acellular 
Pertussis vaccine (TDAP) vaccine (90715) and immunization administration (90471) provided on February 17, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on August 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were given incorrect information from the 
Plan. You also say that you don't feel you should have to pay this bill since you were provided with the 
incorrect information. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for resin-based composite - two surfaces, posterior (D2392) provided on August 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 18, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that although you wanted your 
partner to drive you, the urgent care ordered the ambulance on your behalf. 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 $350 
copayment for each one-way trip for Medicare-covered ambulance services.  
 
You have been asked to pay a $350 copayment for the ambulance services. This item/service falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology provided on August 10, 2022. 
 
You asked the Plan to pay for surgical pathology. You say that the enrollees ordering physician is responsible 
for obtaining prior authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgical pathology 
provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG+ testing provided on June 6, 2022. 
 
You asked the Plan to pay for the Tempus xG+ testing. You say that the Tempus xG+ testing provided on June 
6, 2022, was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet 
criteria for the provided Tempus xG+ testing provided on June 6, 2022. 
 
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 Tempus xG+ testing. Our reviewer says 
that the enrollee did not meet criteria for the provided Tempus xG+ testing provided on June 6, 2022. Our 
physician reviewer found the enrollee has a diagnosis of Other benign neuroendocrine tumors. Genetic testing 
was ordered. Tempus xG+ cancer panel testing does not have FDA approval or clearance as a companion in 
vitro diagnostic, and an FDA-approved or FDA-cleared indication for use in the enrollee's tumor. 
 
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 Tempus xG+ testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xG+ testing provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the form fitting conductive garment for delivery of tens or 
nmes (E0731) provided on June 13, 2022. 
 
You asked the Plan to pay for the form fitting conductive garment for delivery of tens or nmes (E0731). You 
say that the requested form fitting conductive garment for delivery of tens or nmes is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested form fitting 
conductive garment for delivery of tens or nmes. 
 
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 form fitting conductive garment for 
delivery of tens or nmes (E0731). Our reviewer says that the enrollee does not meet criteria for the requested 
form fitting conductive garment for delivery of tens or nmes. Our physician reviewer found Medicare criteria 
do NOT cover TENS for low back pain unless the enrollee is enrolled in an approved clinical study. Therefore, 
this garment is not medically reasonable and 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 the form fitting conductive garment for delivery of tens or nmes (E0731) have 
not been met. Therefore, we decided that the Plan does not have to pay for the form fitting conductive garment 
for delivery of tens or nmes (E0731) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition. 
 
You asked the Plan to pre-approve the dental services. You say that if you do not receive this treatment you 
will continue to need repairs. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive orthodontic treatment of the adult dentition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planning (D4341 and D4342) and the 
gingival irrigation (D4921) provided on August 2, 2022, and August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist di the work because it was needed. 
The Plan denied your request. The Plan says your benefit for the scaling and root planning has already been 
exhausted. Also, the denial of payment the gingival irrigation is correct, because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the scaling and root planning was exhausted on the date of service of February 21, 2021. 
The gingival irrigation is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay for the scaling and root planning (D4341 and D4342) and the gingival irrigation (D4921) 
provided on August 2, 2022, and August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 3, 
2021, through August 9, 2021. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient hospital 
care provided was not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on August 3, 2021 status post a 
mechanical fall on July 31, 2021, where she twisted her right leg and hit the back of her head. The x-ray exam 
of the right knee shows a non-displaced fracture of the medial femoral condyles, diffuse osteopenia, 
degenerative changes, and chondrocalcinosis. The computed tomography (CT) scan of the right lower 
extremity showed no fracture. The enrollee was then admitted for skilled nursing facility placement. The record 
did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollees 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 3, 2021, through August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 7, 2022, and 
June 15, 2022. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided on September 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 76770. You say that the records support the procedure was 
performed. The Plan denied your request. The Plan says the procedure was not supported with the medical 
records. 
 The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
We find that CPT code 76770 is not supported in the medical records. The records do not show that a repeat 
procedure was provided to the enrollee on the date of service at issue. You did not provide all the required 
evidence showing that the excess units were actually provided or were medically necessary. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76770 billed for date of service July 1, 2022.