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

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who 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 treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. When a CGM is not covered, the supplies are also not covered. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor 
(CGM) supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient visit (G0463) and x-ray of spine 
(72100) provided on February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient visit and x-ray. You say that authorization was not 
required. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
 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 the hospital outpatient visit (G0463) and x-ray of 
spine (72100) provided on February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the facility transported 
you to a different facility, and that you did not request the transport. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $300 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 for these 
services. 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 the ambulance services.  
 
Your complaint about the facility transporting you from one area to another is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and eye refraction (92015) provided 
on February 16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and refraction. You say that you feel these services should be 
covered because you have diabetes. The Plan denied your request. The Plan says these services were rendered 
by an OON provider, and the provider did not receive an authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan approved provider. 
 
We looked at the file and the Plan's rules. The record shows that you received these services from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
(92014) and eye refraction (92015) provided on February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 11, 2021, to 
September 9, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be processed 
for payment. The Plan denied your request. The Plan says the non-contracted provider did not submit the RAP 
claim for services for date of service August 11, 2021, to September 9, 2021, until September 17, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from August 11, 2021, to September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal manipulation services (98940) and acupuncture 
services (97810) provided from January 13, 2022, through February 24, 2022, by a chiropractor. 
 
You asked the Plan to pay for the spinal manipulation services and acupuncture services. You say that you 
would like this claim reprocessed and the cost share updated. The Plan denied your request. The Plan says the 
claims in question have processed correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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% coinsurance for Chiropractic Services. 
 The records show that the acupuncture services at are not manual manipulation of the spine. The record also 
indicates that the Plan has correctly processed the 40% coinsurance for the spinal manipulation services.  
Therefore, we decided that the Plan does not have to pay for the spinal manipulation services (98940) and 
acupuncture services (97810) provided from January 13, 2022, through February 24, 2022, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
November 5, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the claim was billed correct 
using the correct place of service. You say that the medical records substantiate the place the service was 
performed, and payment should be issued. The Plan denied your request. The Plan says CPT code 99153 is not 
separately payable when performed by a physician in a facility setting. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital. Based on this information, 
we decided that Medicare rules for coverage of the moderate sedation services (99153) have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided 
on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth office visit provided on February 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth office visit. You say that due to the ongoing crisis, you had less 
staff and unable to obtain authorization.  The Plan denied your request. The Plan says no prior authorization 
was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
telehealth office visit. We found no exception that would require the Plan to pay for the telehealth office visit. 
The records provided for review do not show that the telehealth office visit urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the telehealth office visit provided on February 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 29, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal the 
Plan's decision. 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 July 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 29, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 19, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee dis-enrolled from hospice prior to 
calling for transport. The Plan denied your request. The Plan says 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 ambulance services provided on March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on October 
22, 2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that the cost has accumulated 
over time, and you never received any information about it. The Plan denied your request. The Plan says the 
coinsurance applied is 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 Medicare-covered items.  
 
 
 
 
 You have been asked to pay $27.26 which is 20% of the allowed amount for oxygen equipment. The allowed 
amount is $136.32 (20% x $136.32 = $27.26).  Oxygen equipment falls within the Durable Medical Equipment 
(DME) and Related 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 coinsurance for oxygen 
equipment provided on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to LTACH will give the 
enrollee the best opportunity for continued improvement and recovery from ongoing acute medical conditions. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition they don't meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with acute respiratory failure, 
non-ST-elevation myocardial infarction (NSTEMI) requiring coronary artery bypass grafting (CABG) and 
complicated by atrial fibrillation, dry gangrene, and aspiration pneumonia. The enrollee was treated with 
mechanical ventilation, vasopressors, dialysis, and intravenous medications including antibiotics and 
amiodarone.  
 Trach and percutaneous endoscopic gastrostomy (PEG) were placed. Recent notes describe the enrollee as 
having tried and failed brief attempts at weaning and is still being treated for gangrene on toes, pneumonia, and 
still requiring vasopressors due to hemodynamic instability. The enrollee is receiving appropriate care at the 
present setting. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for mental health visits provided from January 
4, 2022, to February 24, 2022. 
 
You asked the Plan to waive the deductible for mental health visits. You say that you were told this would be 
covered. The Plan denied your request. The Plan says the deductible applied is correct. 
 
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 there is $1000 deductible which applies to outpatient mental health care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Mental Health Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$1000 deductible which applies to outpatient mental health care. This cost sharing is a contractual obligation 
that had not been met at the time mental health visits was received on January 4, 2022, to February 24, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for mental health visits provided 
from January 4, 2022, to February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided on June 22, 
2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that the amount has accumulated 
over time, and you never received any information about it. The Plan denied your request. The Plan says the 
coinsurance applied is 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 Medicare-covered items.  
 
 
 
 
 You have been asked to pay $27.26 which is 20% of the allowed amount for oxygen equipment. The allowed 
amount is $136.32 (20% x $136.32= $27.26). Oxygen equipment falls within the Durable Medical Equipment 
(DME) and Related 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 coinsurance for oxygen 
equipment provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that long term acute care is medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about your condition you do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted to the acute care hospital with mitral valve endocarditis, 
meticillin-sensitive staphylococcus aureus (MSSA) bacteremia, and left calcaneal osteomyelitis requiring 
intravenous antibiotics, wound care, and hemodialysis. Recent notes describe you are responding to treatment 
with a peripherally inserted central catheter (PICC) placed and requiring ongoing antibiotics, dialysis, and daily 
basic wound care. You appear to be more stable and improving and should only require short-term additional 
acute care services that can safely be completed at the current facility until more appropriate for a lower level 
of care.  You are receiving appropriate care at the present setting. You do not require services at the LTACH that are not 
available at the acute care hospital where you are currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on March 16, 2022, 
and March 23, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that this was not surgery so you shouldn't 
be charged this much. The Plan denied your request. The Plan says the copayment applied is 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 $300 
copayment for each Medicare- covered outpatient hospital facility surgery.  
 
 
 
 
 You have been asked to pay a total of $361.44 copayment for both wound care visits. You have been asked to 
pay $180.72 per visit which is less than the standard $300 copayment per visit. Wound care 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 wound care provided on 
March 16, 2022, and March 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of abdomen and pelvis 
(74176) and CT of thorax, diagnostic (71250) provided on December 28, 2021. 
 
You asked the Plan to pay for the CT scans. You say that you were advised that the services denied because 
they were not part of the plan of care. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 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 December 21, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) of abdomen and pelvis (74176) and CT of thorax, diagnostic (71250) provided on December 
28, 2021.