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

 
We decided that the Plan does not have to issue reinstatement of the allowance for the hearing aids (V5298) 
purchased on August 24, 2022. 
 
You asked the Plan to issue reinstatement of the hearing aid allowance. You say that you are requesting a 
reconsideration of the Plans denial. The Plan denied your request. The Plan says an updated claim would need 
to be resubmitted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
reinstatement of the hearing aid allowance have not been met. Specifically, you had indicated the hearing aids 
in this case were returned. The provider should submit an updated claim, so the $1,000 is refunded to the Plan 
unless the provider has issued you the full refund of $1,000 plus the remainder of what was owed. Therefore, 
we decided that the Plan does not have to issue reinstatement of the allowance for the hearing aids (V5298) 
purchased on August 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71275 and 93005 provided on September 6, 
2022. 
 
You asked the Plan to pay for the codes 71275 and 93005. You say that this service was medically necessary. 
The Plan denied your request. The Plan says these codes are not separately payable. 
 
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 codes 71275 and 93005 are not supported in the medical record. Specifically, according to 
Addendum B - Outpatient Perspective Payment System, Payment by HCPCS Code for CY 2022, code 71275 
has a status indicator of Q3. Code 93005 has a status of Q1. These codes were billed the same date of service as 
code 99285 which has a status indicator of V. Based on this information, we decided that Medicare rules for 
coverage of the codes 71275 and 93005 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 71275 and 93005 provided on September 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on September 20, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that these services were provided to you as part of 
the treatment you received at the medical center during the period of September 20, 2022 to 
September 22, 2022, when you were kept for treatment of an acute mental health crisis. You say that during 
those days you were in the center's Emergency Department under protective observation and supervision while 
receiving medication and psychotherapy to treat your condition. The Plan denied your request. The Plan says 
that this provider is not a Medicare Health Plan provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with the network status of the facility 
where you received the services at issue. Additionally, the Plan has not provided a Medicare rule to substantiate 
the denial. Therefore, we decided that the Plan has to pay for psychotherapy provided on September 20, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sunitinib Malate. 
 
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 self-administered drugs are not covered. 
 
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 Sunitinib Malate.  
 
Benefits for these services 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 pre-approve a Freestyle Libre CGM sensor. 
 
You asked the Plan to pre-approve a CGM sensor. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre CGM sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have cancer and have received treatment 
with this oncologist in the past. You would like to receive treatment at this location as soon as possible. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services. 
There are multiple alternative comparable in-network oncology providers available for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal photopheresis (36522) provided on 
August 19, 2022. 
 
You asked the Plan to pay for procedure code 36522. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for procedure code 36522 must be billed 
with specific information. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required second 
diagnosis code, clinical trial number, condition code, modifier, and value code. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the extracorporeal photopheresis (36522) provided on August 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgical procedure performed on 
November 2, 2022. 
 
You asked the Plan to waive the copayment for the surgical procedure. You say that you cannot afford to pay 
the coinsurance for surgery. 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 20% 
coinsurance for outpatient hospital surgery services.  
 
You have been asked to pay $5,037.50, which is less than the actual coinsurance for the surgical procedure. 
The allowed amount is $30,402.09 x 20% coinsurance = $6,081.16, which is more than the billed amount of 
$5,037.50. The surgery procedure falls within the surgery 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 the surgical procedure performed on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies (A4595) provided on October 8, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that the claim was billed in accordance with the 
enrollee's insurance policy allowable, accepted procedure codes, and diagnosis codes according to plan type. 
The Plan denied your request. The Plan says the order date is missing from the submitted physician 
prescription (order). The Plan also says multiple attempts have been made to obtain the documents, but they 
have not been received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that a written order/prescription must include the 
elements listed in the Medicare rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the TENS supplies have been met. The 
Plan made multiple attempts requesting medical records, but they were not received. The record also shows 
that the order date is missing from the submitted prescription, which is a required element. Therefore, we 
decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies 
(A4595) provided on October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for the standard - weight frame 
motorized/power wheelchair (K0010 x 2) provided from April 24, 2021, to June 10, 2021. 
 
You asked the Plan to reimburse the enrollee for the durable medical equipment (DME). You say that the 
enrollee's electric wheelchair was hacked. You say that the enrollee has had to pay out-of-pocket for repairs to 
their electric wheelchair. You also say that you are frustrated with the way the enrollee's Plan operates. The 
Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the durable medical equipment (DME) was not filed until July 14, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to reimburse the enrollee for the standard - weight frame 
motorized/power wheelchair (K0010 x 2) provided from April 24, 2021, to June 10, 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve pulmonary stress testing (94618). 
 
You asked the Plan to pre-approve pulmonary stress testing. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that rules for coverage for out-of-network 
services have not been met. However, the case record does not support that the provider of the requested 
services would be an out-of-network provider. The Plan has not provided any alternative rationales for denial. 
It is the Plans responsibility to substantiate its denial with evidence. In this case, the Plans denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-approve pulmonary 
stress testing (94618).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 11, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 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 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 physician's services provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 83789 for October 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with code 83789 for October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
July 20, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that these services were reported 
correctly. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. These services have 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 codes 87481 and 87653 billed for 
date of service July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 7, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available and requires authorization for certain services. No 
medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been 
documented.   
 
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 an office visit provided on September 7, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for the requested Procrit. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Procrit. Our reviewer says that the 
requested Procrit is medically necessary. Our physician reviewer found the record indicates that the enrollee 
has anemia in stage IV chronic kidney disease. The record indicates that the enrollee has been receiving the 
requested drug and has a history of iron deficiency anemia. The record indicates the enrollee is receiving 
replacement iron therapy. The elements of the coverage criteria are satisfied. The requested service is 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have been met. Therefore, we decided that the Plan has to pre-approve 
Procrit.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary knee 
osteoarthritis confirmed with imaging studies. Her symptoms have not been relieved by conservative 
treatments. She received bilateral Euflexxa injections on February 20, 2023. The standard dosing of Euflexxa is 
at weekly intervals for three weeks. Re-treatment with another series of three Euflexxa injections is not 
medically reasonable and necessary until six months have elapsed since the completion of the last series of 
Euflexxa injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.