Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 19, 
2021 to April 30, 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 that several items and services initially denied due to not having an itemized bill have now been 
identified as routine items and services. 
 
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. That the plan's itemized bill that was provided did not contain information on the 
denial code for each item. The plan's denial cannot be verified in this case. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from March 19, 2021 to April 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886 and 95908 billed for date of service 
May 20, 2022. 
 
You asked the Plan to pay for procedure codes 95886 and 95908. You say that there are no NCCI bundling 
issues for this claim, so codes 95886 and 95908 should be paid. The Plan denied your request. The Plan says 
payment for code 95886 and 95908 is bundled into payment for code 95861. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95886 
and 95908 is a column II code to column I code 95861 with a modifier indicator of 0. Code 95861 was billed on a separate claim for the same date of service by the same provider. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 95886 and 95908 billed for date of service May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a post removal (D2955). 
 
You asked the Plan to pay for a post removal. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says this service has been processed and denied correctly. 
 
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 pay for a post 
removal (D2955).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205-25) provided on August 2, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 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 office visit. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. Procedure report describes emergency department services 
were provided. Documentation supports straightforward medical decision making, and therefore, 99205 is not 
supported by the medical record. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99205-25) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270) provided on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this additional x-ray. 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 June 16, 2022. Therefore, 
we decided that the Plan does not have to pay for bitewings (D0270) provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a straight tip urine catheter to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a straight tip urine catheter from an OON provider. You say that you work 
well with the requested provider who is never late and who provides you care. You say that the requested 
provider advised your urologist that they were in-network with the Plan. The Plan denied your request. The 
Plan says the requested item is available from a provider within the network. 
 
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 
a straight tip urine catheter to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial for admission to an IRF. 
The Plan denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have medical barriers to their rehabilitation program and 
does not require frequent physiatry oversight. The enrollee is unable to respond to intensive rehabilitation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Trelegy. 
 
You asked the Plan to pre-approve Trelegy. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Trelegy.  
 
  Benefits for Trelegy 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 an office visit provided on August 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says services can be obtained from an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on August 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that the requested CGM is medically 
necessary. The Plan denied your request. The Plan says that you are requesting a CGM product that does not 
meet Medicare's definition of durable medical equipment (DME) and, therefore, is not in a defined Medicare 
benefit category. 
 
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. 
 
The records show that you are requesting coverage of a non-adjunctive CGM. As of January 1, 2023, the 
appropriate coding for a non-adjunctive CGM is E2103. The Freestyle Libre 3 is not specified as a product that 
may be billed using code E2103. The Freestyle Libre 3 is not eligible for coverage. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not tried conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that the treatment of varicose veins are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has varicose veins with reflux. It is documented that he does not have 
significant symptoms. It is also documented that he has lower extremity atherosclerotic disease and 
claudication believed to be neurogenic in nature, but no pulse exam was documented. The enrollee does not 
have significant symptoms attributable to his varicose veins and may have a contraindication to saphenous vein 
ablation. Therefore, the documentation does not support the medical necessity of the procedure in question and 
does not describe an indication for treatment. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve venous ablation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance provided on June 4, 2022. 
 
You asked the Plan to pay for the travel allowance. You say that the service was rendered to the enrollee in a 
skilled nursing facility. The Plan denied your request. The Plan says no prior authorization was obtained prior 
to the services being rendered. 
 
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 P6903 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. This code is a statutory exclusion. This code represents an item or service that 
is not in the statutory definition of physician services for fee schedule payment purposes. No RVUS (relative 
value units) or payment amounts are shown for these codes, and no payment may be made under the physician 
fee schedule. 
 We find that CPT code P6903 is not supported in the medical record. Specifically, P6903 is excluded from 
coverage. Based on this information, we decided that Medicare rules for coverage of the travel allowance have 
not been met. Therefore, we decided that the Plan does not have to pay for the travel allowance provided on 
June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on August 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a psychotherapy visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file and, the services can be 
obtained from an in-network provider. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on August 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the observation discharge services provided on August 10, 2022, billed 
with code 99217. 
 
You asked the Plan to pay for the observation discharge services. You say that this is billed correctly as the 
enrollee was discharged from observation care on this date. The Plan denied your request. The Plan says that 
this was billed on the same date as 99239, which is not allowed. 
 
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 has not provided a supported denial rationale in this case. The Plan 
indicates that code 99239 was billed and paid on the same date of service. However, the file does not include 
evidence of this. No claim or remittance showing that code 99239 was paid on the same date is included. We 
find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the 
observation discharge services provided on August 10, 2022, billed with code 99217.  
 
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 pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a CGM sensor. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
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 available in the case record is insufficient to 
support that the enrollee uses insulin with at least three daily injections, requires frequent self-adjustment of 
insulin dosage based on the blood glucose testing results, and has had an in-person visit with their treating 
physician to assess adherence to their CGM regimen and diabetes treatment plan. Based on this information, 
we decided that Medicare rules for coverage of a CGM sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88341 X3) provided from July 17, 
2022, through July 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 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 laboratory services. Our reviewer found documentation 
submitted was reviewed and does not meet criteria. CPT 88341 cannot be verified. Laboratory report 
documents "88342 x 18". Provider states, "We performed 88341-26, 59 X14 on the date of service which you 
paid 13 and denied the other as a duplicate". Documentation is not clear, on how many units were billed. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (88341 X3) provided from July 17, 2022, through July 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that the clinical information provided 
supports the need for the requested item. The Plan denied your request. The Plan says the criteria for coverage 
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 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 Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 sensor.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to correct the cost share for Medicare Part B prescription drugs. We decided that 
the Plan does not have to waive the cost share for Medicare Part B prescription drugs .  
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs Medicare Part B prescription 
drugs provided on October 14, 2022.You say that you disagree with the cost share. The Plan says that this cost 
sharing was charged correctly.  
We decided that the Plan has to correct the cost share for Medicare Part B prescription drugs.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for 
Medicare Part B prescription drugs. 
 
The Plan says you must pay $1.699.46 of the allowed amount of $8,485.44 for Medicare Part B prescription 
drugs. Based on the Plan contract, however, you cannot be asked to pay more than a 20% coinsurance for 
Medicare Part B prescription drugs. The correct coinsurance for the allowed amount is $1,697.01($8,485.44 x 
20% = $1,697.01).   
 
 Therefore, we decided that the Plan has to correct the cost share for Medicare Part B prescription drugs.  
 
We also decided that the Plan does not have to waive the cost share for Medicare Part B prescription 
drugs . 
 
 Therefore, we decided that the Plan does not have to waive the cost share for Medicare Part B prescription 
drugs . 
 
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.