Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 14, 2022. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram provided on April 29, 2022. 
 
You asked the Plan to pay for a mammogram. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 15, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a mammogram 
provided on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 23, 
2022, to November 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $325 
copayment per day for days 1 to 6 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last 
inpatient day. There were two days. 2 x $325 = $650. Therefore, results in the total cost sharing amount of 
$650. 
 
 
 You have been asked to pay a $325 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay on November 23, 2022, to November 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay, and an IRF stay 
provided from September 29, 2022, to October 20, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay, and an IRF stay. You say that you 
should not owe another copayment for going to another facility because you were told to do so by the Plan. 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 $250 
copayment per day for days 1-4 and $0 copayment per day for days 5-90 for each inpatient hospital care 
admission.  
 You have been asked to pay a total copayment of $2,000 for an inpatient hospital stay and an IRF stay. This 
total includes a $1,000 copayment for an inpatient hospital stay beginning on September 29, 2022 ($250 per 
day x 4 days = $1,000) and a $1,000 copayment for an IRF stay beginning on October 7, 2022 ($250 per day x 
4 days =$1,000). This item/service falls within the inpatient hospital care 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 reduce the copayment for an inpatient hospital stay, and an IRF stay provided from September 
29, 2022, to October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are concerned that the 
CGM has not been approved. The Plan denied your request. The Plan says the Medicare criteria was 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 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the emergency department (ED) 
services provided on September 3, 2022. 
 
You asked the Plan to make additional payment for the ED services. You say that you do not hold a contract 
with the Plan and cannot be bound to any contractual fee schedule. The Plan denied your request. The Plan says 
this was paid correctly based on the OPPS. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to the COVID-19 PHE, IFEDs, such as the 
facility at issue, could not be paid by Medicare as they are not recognized provider types. However, Medicare 
allowed such facilities to enroll as temporary hospital which made them eligible for reimbursement. As a 
temporary hospital offering outpatient services, payment is made in accordance with the OPPS. 
 
We looked at the file and Medicare rules. It is not clear the facility at issue is enrolled as a temporary hospital 
with Medicare. This would generally mean that no payment can be made; however, the Plan elected to make 
payment as if the facility was a temporary hospital subject to OPPS. Though the Plan made payment on a 
single line item on the remittance, this payment amount was calculated based on the OPPS payment rates for all 
the billed codes for which separate payment is allowed. We find that the Plan correctly processed the claim 
paying the amount due per the OPPS. None of the services billed were specifically denied. Based on this 
information, we decided that Medicare rules for coverage of the ED services have not been met. Therefore, we 
decided that the Plan does not have to make additional payment for the emergency department (ED) services 
provided on September 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (22612, 22840). 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is 
considered experimental and investigational as its efficacy has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Minuteman procedure (22612, 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214-25-EJ), therapeutic, prophylactic, or 
diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (96374-59-
EJ), infusion, normal saline solution, sterile (500 ml = 1 unit) (J7040-EJ),  introduction of needle or 
intracatheter, vein (36000-59-EJ), intravenous infusion, for therapy, prophylaxis, or diagnosis (specify 
substance or drug); initial, up to 1 hour (96365-59-EJ), intravenous infusion, for therapy, prophylaxis, or 
diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure) (96366-59-EJ) provided on October 6, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The modifier EJ should only be used with J codes Therefore, 99214, 96374, 96365 and 96366 are not covered 
as billed. The provider can submit a corrected bill to get paid for these codes. Since the provider also billed 
code 96374, that would seem to indicate this was the initial dose, in which case the EJ modifier would not be 
appropriate for J7040, because that is to be used for subsequent administration. Furthermore, we find that 
procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that procedure 
code 36000 is not separately payable. 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 the office visit 
(99214-25-EJ), therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, 
single or initial substance/drug (96374-59-EJ), infusion, normal saline solution, sterile (500 ml = 1 unit) 
(J7040-EJ),  introduction of needle or intracatheter, vein (36000-59-EJ), intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (96365-59-EJ), intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure) (96366-59-EJ) provided on October 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient rehabilitation services and an 
outpatient surgery provided on August 24, 2022, to August 25, 2022. 
 
You asked the Plan to waive the cost share for outpatient rehabilitation services and an outpatient surgery. You 
say that you feel the cost share should be less. 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 $40 
copayment per visit for outpatient rehabilitation services and a $325 copayment for outpatient surgery.  
 
You have been asked to a $40 copayment per visit for outpatient rehabilitation services and a $325 copayment 
for outpatient surgery. The total amount for outpatient rehab services is $80 ($40 x 2 visits = $80). The total 
amount for all services rendered is $405 ($325+ $80 = $405). This item/service falls within the outpatient rehabilitation services and outpatient surgery benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share 
for outpatient rehabilitation services and an outpatient surgery provided on August 24, 2022, to August 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to pre-approve this CGM. 
The Plan denied your request. The Plan says the requested CGM has been correctly denied. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the item should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the item denied correctly as they do not meet the clinical 
requirements to be approved. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pay for the CGM. You say that the item should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the item denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial and are 
requesting reconsideration for additional mileage trips. The Plan denied your request. The Plan says you are 
requesting an additional 31 miles for a total of 81 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 72 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient implantation of neuroelectrodes (64555, 
77003). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that at this point having failed most 
conservative therapies, peripheral nerve stimulation is warranted and medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare medically necessary criteria.  
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 the outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic degenerative neck pain. The peripheral nerve stimulator 
device is experimental for chronic degenerative neck pain. It is not an approved diagnosis for 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient implantation of neuroelectrodes (64555, 77003).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subcutaneous hormone pellet implantation (11980). 
 
You asked the Plan to pre-approve the procedure. You say that you as for consideration to have this procedure 
covered under your Plan in light of the information provided as medically necessary in your particular 
situation. The Plan denied your request. The Plan says Bioidentical compounded hormone therapy for the 
diagnosis, prevention, and/or treatment of diseases and health related symptoms or conditions are considered 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
subcutaneous hormone pellet implantation (11980).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
diagnostic test provided on November 22, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a diagnostic test. You 
say that you disagree with 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 20% 
coinsurance and a $175 copayment, for Medicare Part B prescription drugs and outpatient diagnostic 
tests/outpatient Hospital.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $175 copayment 
for a diagnostic test. The total allowed amount for the prescription drugs is $1,350.60. You are being asked to pay $270.12 ($1,350.60 x 20% = $270.12). You are being asked to pay $62.37 for the diagnostic test which is 
less than the required amount of $175. The total amount you are being asked to pay for the services rendered is 
$332.49 ($270.12 + $62.37 = $332.49). This item/service falls within the Medicare Part B prescription drugs 
and outpatient diagnostic tests/outpatient Hospital benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost share for Medicare Part B prescription drugs and a diagnostic test provided on November 22, 2022.