Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM system. You say that the enrollee has frequent 
episodes of hyperglycemia and needs to have sensors to alert him when he has low blood sugar. The Plan 
denied your request. The Plan says a CGM is not covered under Medicare if the enrollee is not on insulin. The 
enrollee does not meet criteria for approval of the requested system. 
 
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 Freestyle Libre 2 CGM system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days at a skilled nursing facility (SNF) from 
February 10, 2023, forward. 
 
You asked the Plan to pre-approve additional SNF care. You say that you need additional care at the SNF. The 
Plan denied your request. The Plan says you have exhausted your SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from May 30, 2022, to 
February 9, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional days at a skilled nursing facility (SNF) from February 10, 2023, 
forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more rehabilitation than what is being 
offered at the current facility. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
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 the clinical documentation shows that the enrollee has functional impairments, however no active medical issues have been documented and is currently medically stable making functional 
progress in the skilled nursing facility setting. Thus, the complexity of the enrollee's documented nursing, 
medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 10, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 93355. You say that services were done separately according to 
modifier 59. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 93355. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 93355. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93355 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93355 billed for date of service May 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service May 22, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service May 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19342 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 19342. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 19342 is bundled into payment for code 19316. 
 
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 19342 
is a column II code to column I code 19316. This claim has not been billed with an appropriate modifier to bypass the edit. 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 code 19342 billed for date of service August 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxychloroquine Sulfate. 
 
You asked the Plan to pre-approve Hydroxychloroquine Sulfate. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxychloroquine 
Sulfate.  
 
Benefits for Hydroxychloroquine Sulfate 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 
minutes (D9239), and each intravenous moderate (conscious) sedation/analgesia subsequent 15 minute 
increment (D9243 x2). 
 
You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), and each intravenous moderate (conscious) sedation/analgesia subsequent 15 minute increment 
(D9243 x2). You say that you say that you need sedation as you have a weak heart. You also say that you 
cannot handle having to be stabbed 6 times or more for the numbing for fear of having a heart attack. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
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 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and each intravenous moderate 
(conscious) sedation/analgesia subsequent 15 minute increment (D9243 x2) 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 intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), and each intravenous moderate (conscious) sedation/analgesia 
subsequent 15 minute increment (D9243 x2). Our reviewer says that these services are medically necessary. 
Our physician reviewer found the documentation indicates that the enrollee's provider requests that intravenous 
sedation/analgesia be used for multiple extractions, tooth #'s 6-11 and 13, due to the enrollee's history of heart 
disease and anxiety. It is my opinion that these services are medically reasonable and necessary due to the 
number of extractions and time involved for the procedure and the enrollee's medical history. 
 
  
 
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 intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), and each intravenous moderate (conscious) sedation/analgesia subsequent 15 minute increment 
(D9243 x2). have been met. Therefore, we decided that the Plan has to pre-approve intravenous moderate 
(conscious) sedation/analgesia- first 15 minutes (D9239), and each intravenous moderate (conscious) 
sedation/analgesia subsequent 15 minute increment (D9243 x2).  
 
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: 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 LTACH services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says it is not safe to leave the hospital at this 
time the enrollee is receiving the care needed in the current hospital and there is no need to transfer to the 
LTACH at this time. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SMN1 (survival of motor neuron 1, telomeric) gene analysis 
(81329) provided on June 24, 2022. 
 You asked the Plan to pay for SMN1 gene analysis. You say that this service was medically necessary. The 
Plan denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, SMN1 gene analysis, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for SMN1 (survival of motor neuron 1, telomeric) gene analysis (81329) provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on August 4, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
The physician order is not itemized. Outreach by the plan to the enrollee has confirmed this item was never 
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595) 
provided on August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service 
September 30, 2022. 
 
You asked the Plan to pay for procedure code(s) G0416. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) G0416. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) G0416. Based on this information, 
we decided that Medicare rules for coverage of procedure code G0416 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service September 30, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-rays provided on August 18, 2022. 
 
You asked the Plan to pay for the chest x-rays. You say that the services should be paid. 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 the chest x-rays 
provided on August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on September 29, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copayment. 
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 $15 
copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $15 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/x-rays benefits 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 x-ray 
services provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on August 05, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you are requesting reconsideration. 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 acupuncture provided on 
August 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on July 9, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you disagree with the 
copayment. 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for urgent care visit. This item/service falls within the urgently 
needed 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 urgent care visit provided 
on July 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote interrogation device services 
provided from February 11, 2022, to July 16, 2022. 
 
You asked the Plan to waive the copayment for the remote interrogation device services. You say that you 
previously did not have to pay for this service. 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 for physician specialist services (including surgery second opinion, telehealth services, home 
infusion professional services, and urgently needed services). 
 
 
 
 
 You have been asked to pay a $209.28 copayment for the remote interrogation device services because the 
allowed amount for these services is less than $40 ($34.88 copayment x 6 services = $209.28). These 
items/services fall within the physician/practitioner services, including doctors office visits 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 the remote interrogation device services provided from 
February 11, 2022, to July 16, 2022.  
 
Your complaint about feeling that you should not be charged for this service if you are not present 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.