Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), intravenous 
moderate (conscious) sedation/analgesia (D9239, D9243) and an extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) provided on November 16, 2022, to November 23, 2022. 
 
You asked the Plan to pay for dental services. You say that these 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. Therefore, we decided that the Plan does not have to pay for 
panoramic radiographic image (D0330), intravenous moderate (conscious) sedation/analgesia (D9239, D9243) 
and an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on 
November 16, 2022, to November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you need this CGM. The Plan denied your request. 
The Plan says the medical criteria for a CGM 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the iron sucrose injections and saline injections 
provided on October 25, 2022, and November 8, 2022. We also decided that the Plan does not have to waive 
the coinsurance for the drug administrations provided on October 25, 2022, and November 8, 2022.  
 
You asked the Plan to reduce the coinsurance for the iron sucrose injections, saline injections, and drug 
administrations. You say that you were not given multiple injections on the same date. The Plan says that this 
cost sharing was charged correctly. 
 We decided that the Plan has to waive the coinsurance for the injections.  
 
You have been asked to pay a 20% coinsurance for the iron sucrose injections and saline injections. According 
to Medicare, the iron sucrose injections (J1756) and saline injections (J7050) that assessed a cost share amount 
are considered packaged codes and are not separately payable. These codes are also excluded from the 
physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the injections 
provided on October 25, 2022, and November 8, 2022. 
 
We also decided that the Plan does not have to waive the coinsurance for the drug administrations. 
 
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 in-network Medicare Part B drug administration.  
 
You have been asked to pay 20% coinsurance of the allowed amount for each drug administration service. 
These items/services fall within the Medicare Part B drugs benefit category. 
 
Date of Service CPT Code Allowed Amount Coinsurance 
October 25, 2022 96365 $120.99 $24.20 
October 25, 2022 96366 $66.97 $13.39 
November 8, 2022 96365 $120.99 $24.20 
November 8, 2022 96366 $133.94 $26.79 
 
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 the drug administration provided on October 25, 2022, and 
November 8, 2022. 
 
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 pay for foot orthotics provided on October 21, 2022. 
 
You asked the Plan to pay for foot orthotics. 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 foot orthotics provided 
on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), pontic - porcelain/ceramic (D6245) and retainer crown - porcelain/ceramic (D6740). 
 
You asked the Plan to pre-approve dental services. You say that you do not understand why the requested 
services are not covered. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
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. Surgical placement of implant 
body: endosteal implant (D6010), pontic - porcelain/ceramic (D6245) and retainer crown - porcelain/ceramic 
(D6740) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010, D6245 and 
D6740 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve surgical placement of implant body: endosteal implant (D6010), pontic - porcelain/ceramic 
(D6245) and retainer crown - porcelain/ceramic (D6740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader/Monitor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader/Monitor. You say that on your medical records 
it should be stated that you have been taking the insulin for approximately 3 years. The Plan denied your 
request. The Plan says you do not require insulin three or more times daily. 
 
 
 
 
  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen 
and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre 2 Reader/Monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Reader/Monitor.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on October 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that you were not made aware of additional charges. 
The Plan denied your request. The Plan says the service exceeds the maximum benefit allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the testing at issue was previously provided on January 11, 2021, and paid for by the Plan. This 
testing is only covered once every 24 months.  Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the testing services provided on October 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for SNF care provided from July 1, 2022, to 
July 13, 2022. 
 
You asked the Plan to waive the cost sharing for SNF care. You say that you are vehemently submitting a 
rebuttal, complaint, and grievance regarding your copayment. You say you do not owe any out-of-pocket fee of 
any kind. 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 your maximum out-of-
pocket is $800. Your contract with the Plan also clearly says that for skilled nursing facility care, enrollees 
must pay $0 copayment each day for days 1 to 20; $100 copayment each day for days 21 to 28; $0 copayment 
for additional days, up to 100 days. 
 
You have been asked to pay $623.66 for SNF care. This is less than the standard amount because you had met your out-of-pocket maximum with this claim. This item/service falls within the skilled nursing facility (SNF) 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost sharing for SNF care provided from July 1, 
2022, to July 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
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 November 26, 2022. 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 provided on November 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) and a 
power seat elevation feature (E2300) for a power wheelchair. 
 You asked the Plan to pre-approve the expandable controller and power seat elevation feature. You say that 
these features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation features are non-covered. 
Expandable controllers are covered when medically necessary. 
 
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 expandable controller and power 
seat elevation feature. Our reviewer says that the requested features are not medically necessary. Our physician 
reviewer found the records show that the enrollee has the ability to operate the power functions with the 
standard switches. The power seat elevation feature is non-covered. 
 
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 expandable controller and power seat elevation feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, 
E2377) and a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 52 additional trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the enrollee needs to have regular follow-
up visits with you and multiple specialties. The Plan denied your request. The Plan says the enrollee has 
already exhausted the covered 12 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 52 additional trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed with the correct procedure 
and modifier combination. The Plan denied your request. The Plan says code 99153 is not payable in the 
facility setting. 
 Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for procedure code 99153 billed for date of service November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair. 
 
You asked the Plan to pre-approve a bath/shower chair. The Plan denied your request. The Plan says this item 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation adequately supports the level 
billed. The Plan denied your request. The Plan says the billed code remains not supported. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity.  We find that CPT code 99220 is not supported in the medical record. The records show the enrollee presented 
to the emergency department with dizziness. There was no report of chest pain, shortness of breath, fever, 
chills, or weakness. The enrollee appeared to be in no acute distress. The records report that the enrollees 
symptoms were mild. The enrollees problems were not of high severity. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99220 billed for date of service June 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment provided on August 
26, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring treatment. 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 remote physiologic 
monitoring treatment provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services (99490) provided on 
August 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that you were short staffed 
during the COVID-19 pandemic, which caused charting delays as well as delays in uploading files to billing 
staff. The Plan denied your request. The Plan says these services were rendered by an OON 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 the chronic care management services (99490) 
provided on August 31, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a commode chair (E0163) provided on June 6, 2022. 
 
You asked the Plan to pay for the commode chair. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0163 is not supported in the medical record. Specifically, the claim was submitted 
with frequency code 8, which indicates a request to cancel or void the claim. Based on this information, we 
decided that Medicare rules for coverage of the commode chair have not been met. Therefore, we decided that 
the Plan does not have to pay for a commode chair (E0163) provided on June 6, 2022.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 has no complex functional impairments or active medical 
comorbidities that would require an acute hospital inpatient stay with an interdisciplinary approach. 
 
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.