Persius/hicric huggingface dataset:
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 for 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service September 9, 
2022. 
 You asked the Plan to pay for procedure code 71250. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275. 
 
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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service September 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on August 18, 2022, to September 
19, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are appealing with supporting records. 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 chiropractic care 
provided on August 18, 2022, to September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring provided on October 28, 
2022, to October 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for remote physiologic monitoring. You say that it is the responsibility of the facility 
to obtain prior authorization. The Plan denied your request. The Plan says the services can be obtained from an 
in-network 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 remote physiologic monitoring provided on 
October 28, 2022, to October 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided on August 30, 2022. 
 
You asked the Plan to pay for the acupuncture treatment. The Plan denied your request. The Plan says no more 
than 20 acupuncture treatments may be administered annually. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 We looked at the file, the Plans rules and the Medicare rules. Based on this information, we decided that the 
rules for coverage of the acupuncture services have not been met. Specifically, you have exceeded the benefit 
limit. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided on 
August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy provided on April 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient therapy. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
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 outpatient therapy provided on April 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission following a right total knee 
arthroplasty (27447). 
 
You asked the Plan to pre-approve the inpatient admission. You say that you feel it is extremely unrealistic to 
treat this enrollee in an outpatient setting. The Plan denied your request. The Plan says an inpatient admission 
is not medically necessary for the requested right total knee arthroplasty. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission following a right total 
knee arthroplasty are met in this case. Our physician reviewer found the detailed documentation is not evident 
regarding a significant past and/or current medical history that would place this enrollee at increased risk for 
peri-surgical complications requiring an inpatient stay. The past medical history that has been noted, was 
clarified by cardiology on September 11, 2022. Our reviewer found that the enrollee was noted to have no 
contraindications from a cardiovascular standpoint to surgery, as their perioperative risk is low. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Our physician reviewer also found that the record does not show that the admitting 
physician reasonably expects that the enrollees necessary hospital care will span two midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission following a right total knee arthroplasty (27447).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic lab testing provided on August 29, 2022. 
 
You asked the Plan to pay for diagnostic lab testing. You say that the provider who ordered the labs was in-
network, this should be covered. 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 diagnostic lab testing 
provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and appliance 
(E0673) provided on June 22, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) and appliance (E0673) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 the 
application of desensitizing medicament (D9910) provided on November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on October 3, 2022, to October 17, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $5,948.20. You are being asked to pay $1,189.64 ($5,948.20 x 20% = 
$1,189.64). This item/service falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs provided on October 3, 2022, to 
October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on September 30, 2022. 
Additionally, we decided that the Plan does not have to waive the copayment for the chiropractic manipulative 
treatment (98941) provided on September 30, 2022. 
 
You asked the Plan to pay for the office visit. Additionally, you asked the Plan to waive the copayment for the 
chiropractic manipulative treatment.  
  
You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your 
request. The Plan says this service is not a covered benefit. Additionally, the Plan says the copayment has been 
applied correctly to the chiropractic service provided.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Medicare-covered chiropractic services rendered by an out-of-network provider.   
 
You have been asked to pay a $25 copayment for the Medicare-covered chiropractic service rendered by an 
out-of-network provider. 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. In addition, the records show that the service at issue is not manual manipulation of the spine. Therefore, 
we decided that the Plan does not have to pay for the office visit (99203) provided on September 30, 2022. 
Additionally, we decided that the Plan does not have to waive the copayment for the chiropractic manipulative 
treatment (98941) provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on September 
8, 2022, and core build up on tooth #18 (D2950) and a pulp cap on tooth #18 (D3120) provided on September 
16,2022. 
 
You asked the Plan to pay for the x-rays, core build up, and a pulp cap. You say that you were told the dental 
services would be covered. The Plan denied your request. The Plan says that core build up (D2950) and a pulp 
cap (D3120) are not covered by your supplemental dental benefits. The Plan also says that your benefit for 
periapical x-rays has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, core build up and pulp caps are not 
among those covered under this benefit. The record shows your benefit for periapical x-rays was exhausted on 
date of service September 8, 2022. Therefore, we decided that the Plan does not have to pay for additional 
periapical x-rays (D0230) provided on September 8, 2022, and core build up on tooth #18 (D2950) and a pulp 
cap on tooth #18 (D3120) provided on September 16,2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care 
 
You asked the Plan to waive the cost share for inpatient hospital care. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a 2% coinsurance which applies to inpatient hospital care. The total 
allowed amount for the inpatient care $1,2913.87. You are being asked to pay $258.28 ($1,2913.87 x 2% = 
$258.28). The $258.28 will go towards your out-of-pocket maximum of $2000. 
 
The item or service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 2% 
coinsurance which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time inpatient hospital care was received on September 14, 2022. Therefore, we decided that 
the Plan does not have to waive the cost share for inpatient hospital care
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on October 11, 2022. 
 You asked the Plan to pay for the contact lenses. You say that you believe the two different contact lenses 
should be covered because they are medically necessary. The Plan denied your request. The Plan says the 
benefit limit is exhausted 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with an allowance up to $350. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $350 towards the contact lenses which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses 
provided on October 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73100 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for the billed services. You say that separate procedures were performed. The Plan 
denied your request. The Plan says an anatomical modifier was not appended. 
 
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 73100 is radiologic examination, wrist; 2 views. We find 
that CPT code 73100 was not billed with a modifier to indicate which wrist was the x-ray was performed on.  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 73100 billed for date of 
service September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 18, 
2022, to June 29, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee needed a thoracic 
surgeon to operate and the hospital they were transferred from was unable to treat them, which is why they 
needed to be transferred to a different facility. You also say that you were told the enrollee had authorization 
for the services. The Plan denied your request. The Plan says there was no mention of an attempt to transfer the 
enrollee to multiple other hospitals, which were all closer and could have managed this enrollee's care at a 
higher level. The Plan also says these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient services having been 
provided at the hospital the enrollee was transferred to are met in this case. Our physician reviewer found there 
was no explanation for not attempting to transfer the enrollee to closer capable hospital settings. Our reviewer 
also found that although the enrollee was expected to require at least 2 midnights at the hospital on admission, 
the admission to this specific hospital is not supported in the documentation. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from May 18, 2022, to June 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown 
(D6058), custom fabricated abutment  includes placement and (D6057) for all tooth #'s 4, 5, 6, 8, 9, 12 and 14. 
 
You asked the Plan to pre-approve an abutment supported porcelain/ceramic crown (D6058), custom fabricated 
abutment  includes placement and (D6057). You say that this is an urgent matter and should be addressed as 
this is affecting you from eating properly. You also say this is making you upset and do not have the money to 
pay out-of-pocket for the services needed. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 pre-approve an 
abutment supported porcelain/ceramic crown (D6058), custom fabricated abutment  includes placement and 
(D6057) for all tooth #'s 4, 5, 6, 8, 9, 12 and 14.  
 
Your complaint about the authorization being denied 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.