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

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided October 10, 2021. 
 
You asked the Plan to pay for supply allowance for CGM. You say that you have attached all supporting 
documentation. Please reprocess the claim. The Plan denied your request. The Plan says other documentation 
referenced on the claim was not received. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for supply allowance for CGM. 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 diabetes mellitus. The enrollee is not insulin treated with three or 
more daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. 
The enrollees insulin treatment regimen does not require frequent adjustment by the enrollee on the basis of 
BGM or CGM testing results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of supply allowance for CGM have not been met. Therefore, we decided that the 
Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all 
supplies and accessories, 1 month supply (K0553) provided October 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
2 or more power seating system motors (E2311) expandable controller (E2313) harness (E2311) power seating 
extra heavy-duty upgrade (K0108) curved powder coated sheet (K0108) offset back posts (K0108) extra-long 
seat depth (K0108) custom rear wheel offset (K0108) transport tiedown (K0108) LED safety illumination 
package (K0108) drink holder (K0108) and Linx remote color touchscreen display (K0108). 
 
You asked the Plan to pre-approve the upgraded power wheelchair accessories. You say that please review for 
reconsideration of the power wheelchair requested. The Plan denied your request. The Plan says the approved 
power options come with their own switches. Wheelchair seat and back cushion codes are all inclusive and 
cannot be billed separately. The transport tiedowns, LED safety illumination package, and drink holder do not 
serve a medical purpose. 
 
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 upgraded power wheelchair 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case the enrollee has a neurologic disorder with 
functional deficits. He meets criteria for use of a power mobility device. The requested accessories are not 
medically necessary as he does have use of his hands and can operate and control the power options using the 
switches that are included in the basic wheelchair. 
 
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 upgraded power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 2 
or more power seating system motors (E2311) expandable controller (E2313) harness (E2311) power seating 
extra heavy-duty upgrade (K0108) curved powder coated sheet (K0108) offset back posts (K0108) extra-long 
seat depth (K0108) custom rear wheel offset (K0108) transport tiedown (K0108) LED safety illumination 
package (K0108) drink holder (K0108) and Linx remote color touchscreen display (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement (D6930), periodic oral evaluation (D0120), 
bitewing radiographic images (x-ray) (D0274), and cleaning (D1110), provided on December 6, 2021, and 
December 9, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says dental code D6930 is not a covered service and you obtained these services 
out-of-network, therefore the cost share is correct. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the re-
cement (D6930), periodic oral evaluation (D0120), bitewing radiographic images (x-ray) (D0274), and 
cleaning (D1110), provided on December 6, 2021, and December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monitoring device (A9279) provided October 26, 2021. 
 
You asked the Plan to pay for the monitoring device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the billed code is not eligible for payment. 
 
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 find that CPT code A9279 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, the code billed has a status of "I" and is invalid for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of the monitoring device have not been met. 
Therefore, we decided that the Plan does not have to pay for a monitoring device (A9279) provided October 
26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical radiographic images (D0220), 
extraction (D7140), and limited oral evaluation (D0140), provided on December 21, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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. Specifically, the services are not listed in the Plan's benefit chart. 
Therefore, we decided that the Plan does not have to pay for the intraoral periapical radiographic images 
(D0220), extraction (D7140), and limited oral evaluation (D0140), provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided June 9, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were at work and they called an 
ambulance. You do not believe you should be charged the full price for not being transported. The Plan denied 
your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport occurs, then 
there is no Medicare covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 9, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (92014, 92015, V2203, V2020) provided 
December 16, 2021. 
 You asked the Plan to pay for the vision services. You say that the services should be covered as you had a 
referral from your primary physician. The Plan denied your request. The Plan says the plan already paid the 
maximum amount of the vision services. 
 
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 offers an allowance of up to $60 per calendar year for a routine vision exam, including 
refraction, and an allowance of up to $300 per calendar year for a combination of routine prescription contacts, 
routine prescription lenses, routine vision frames, and/or upgrades, such as tinting. 
 
We looked at the file and the Plan's rules. The plan paid the allowable $360 towards the vision services. The 
remaining amount is the enrollee's responsibility. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
vision services (92014, 92015, V2203, V2020) provided December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 27, 
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 Current Procedural Terminology (CPT) code 83789-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately.  
 
 
 The services at issue in this case are for the purpose of specimen validity testing. 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 laboratory services provided to the enrollee on October 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on September 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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing. 
 
Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. 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 GeneSight test provided to the enrollee on September 30, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve Kerendia. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Kerendia.  
 
Benefits for Kerendia 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided September 
4, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the continuous glucose monitor 
was medically necessary. The Plan denied your request. The Plan says the documentation does not support the 
billed services. 
 
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 record does not contain a valid physician order for the supplies provided in this case. 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 a continuous glucose monitor (K0553) provided September 4, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
December 1, 2021. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services received on August 25, 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 this service is not covered under your contract. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services received on August 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, immune globulin, (Gammagard liquid), non-
lyophilized, (e.g., liquid), 500 mg (J1569) provided November 6, 2021. 
 
You asked the Plan to pay for the immune gamma-globulin injection. You say that please reprocess for 
payment. The Plan denied your request. The Plan says the records do not support that the enrollee meets the 
criteria for the requested IVIG therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the immune gamma-globulin injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's diagnosis was one of an autoimmune autonomic 
ganglionopathy. The enrollee is not noted to have a diagnosis or condition listed within the LCD/NCD for 
which IVIG is otherwise covered. There was otherwise no evidence of rapid progression of the disease or 
relapse or when other forms of treatment have failed or are contraindicated. In as much the requested service 
would not have otherwise met criteria for coverage at this time. 
 
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 immune gamma-globulin injection have not been met. Therefore, we 
decided that the Plan does not have to pay for injection, immune globulin, (Gammagard liquid), non-
lyophilized, (e.g., liquid), 500 mg (J1569) provided November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 15, 
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 CMS consolidates into dialysis services the laboratory testing related to the treatment of ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (C9803, U0004, U0005, 99282) 
provided November 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee's primary insurer must process the claim 
first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the inpatient hospital services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital services (C9803, U0004, U0005, 
99282) provided November 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 13, 
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 there was no documented acute, urgent, or emergent condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport on October 13, 2021. The 
documentation does not support that the ambulance transport on October 13,2021 was medically reasonable 
and necessary for the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services (86077) provided on August 
7, 2021. 
 
You asked the Plan to pay for blood bank physician services. You say that this is supported in the records. The 
Plan denied your request. The Plan says the billed units exceed MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for blood 
bank physician services (86077) provided on August 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
21, 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 the services should be not be reported separately. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 
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 this claim does not meet coding standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on June 16, 2021.