Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on September 28, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should 
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $250 
copayment for Ambulance Services.  
 
 
 You have been asked to pay a $250 copayment for ambulance transportation. 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 ambulance transportation services provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay any additional reimbursement for eyewear and vision services
provided on July 15, 2021.
You asked the Plan to pay any additional reimbursement for additional reimbursement for vision services
provided on July 15, 2021. You say that the Plan should pay more of the cost of this eyewear. You do not
believe the $250 benefit was fully applied. The Plan denied your request. The Plan says the remaining cost is
your financial responsibility after the application of the $250 maximum benefit. Maximus partially overturned
the Plans denial. The Plan requested a reopen and provided additional information. The Plan explains that the
claim shows the retail value of the eyewear was $289 and $159 totaling $448. The $250 benefit was applied
leaving a balance of $198.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services.
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 has provided documentation to show the $250 benefit was
applied in full. Therefore, the $198 balance is the remaining financial liability. Therefore, we decided that the
Plan does not have to pay any additional reimbursement for eyewear and vision services provided on July 15,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says for the first 100 days in a skilled nursing facility, medications/items that are covered 
under Part B are covered under Part A. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the monitor is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on November 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you are requesting reconsideration for the full 
claim. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
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 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 services provided on November 18, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection procedure (38792) provided on April 22, 2021. 
 
You asked the Plan to pay for the injection procedure. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that CPT code 38792 is included in CPT 
code 38900. 
 
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 38792 is injection procedure; radioactive tracer for identification of sentinel node. 
 
We asked our coder 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 injection procedure. Our reviewer says that CPT code 
38792 meets criteria for billing and reimbursement consideration. Our reviewer found typically, a radioactive 
injection is given prior to the surgery, and they non-radioactive injection is given during the surgery.  In this 
case the surgeon has performed both procedures, and therefore should be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection procedure have been met. Therefore, we decided that the Plan has 
to pay for the injection procedure (38792) provided on April 22, 2021.  
 
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 waive the coinsurance for the knee brace (code L1846) provided on 
September 7, 2021 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you no longer want to use it, so 
the charges should be waived. The Plan denied your request. The Plan says the coinsurance amount charged is 
correct. 
 
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 Medicare-covered items with a total rental or purchase price of $50.01 or more of the Medicare 
allowable rate per item.  
 
 
 
 
 You have been asked to pay $178.95, which is 20% of the Plans allowed amount for the knee brace ($894.76). 
A knee brace falls within the Durable Medical Equipment (DME) and Related Supplies 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 the knee brace (code L1846) provided on September 7, 
2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre sensor kit. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for continuous glucose 
monitors and related supplies have not been met. 
 
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 pre-approve a Freestyle Libre sensor kit. Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that the Medicare criteria require that you to be taking 3 shots of insulin daily and that the doses be adjusted frequently based on the blood glucose level. It is unclear from the provided medical records that 
you are indeed taking Basaglar 3 times daily and it is further unclear if the dose is being adjusted based on 
blood glucose level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre sensor kit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the portable oxygen system provided on 
November 11, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen system. You say that you have never been 
charged in the past so these charges should be waived. The Plan denied your request. The Plan says the 
coinsurance amount charged is correct. 
 
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 10% 
coinsurance for covered items and related supplies. Covered items include, but are not limited to: oxygen 
equipment.  
 You have been asked to pay $4.70, which is 10% of the plans allowed amount ($47), for the portable oxygen 
system. A portable oxygen system falls within the Durable Medical Equipment (DME) and Related Supplies 
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 the portable oxygen system 
provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. We overturned the Plans denial for
insufficient claim information. The Plan requested a reopen and provided additional information. The Plan
states that the non-participating provider appealed the unbundled service of 99205 rendered on April 08, 2021.
The Plan originally denied and upheld the denial per Medicare guidelines a Procedure to Procedure (PTP)
edit exists between 77263, 77470, and 77335 and 99205. The Plan argues that code 99205 is a column 2 code
to column codes 77263, 77470, and 77334. A search of CMS.Gov PTP edit shows denied code 99205 has
an existing relationship with billed codes 77263, 77470 and 77334. Medicare coding rules indicate code 99205
is found under Column Two of the edit pair where code 77263 found under Column One. Medicare coding
rules indicate the code 99205 is found under Column Two of the edit pair where code 77334 is found under
Column One. Medicare coding rules indicate the code 99205 is found under Column Two of the edit pair for
code 77470 is found under Column One. Per the Medicare Claims Processing Manual, Chapter 23 - Fee
Schedule Administration and Coding Requirements, Section 20.9.3.1: A denial of services due to a Procedure
to-Procedure (PTP) edit is a coding denial. Most of these PTP edits have a modifier indicator of 1, which
indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not
billed with this PTP code edit and Column two code is denied as the mutually exclusive procedures
cannot reasonably be performed at the same anatomic site or same beneficiary encounter.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
appropriate modifiers. In this case, the claim submitted could not be paid as billed due to the omission of a
required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for physician services provided to the enrollee on April 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
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 Prednisone for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on November 
9, 2021. 
 
You asked the Plan to waive the copayment for specialist services. You say that were not seen by the specialist 
so you should not be charged for a specialist visit. The Plan denied your request. The Plan says the copayment 
amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare covered services provided by other healthcare professionals in a specialist's office.  
 
 
 
 
 You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist services provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits on June 26, 2021, and July 
27, 2021. 
 
You asked the Plan to waive the copayment for the office visits. You say that the services were billed by a 
different provider. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 
copay for each Medicare-covered primary care doctor visit.  
 
 
 
 You have been asked to pay a $20 copay for each office visit. There were two visits, making the total copay 
$40. The office visits fall within the Physician/Practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visits on June 26, 2021, and July 27, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) mental health counseling visits to be 
provided by a provider not certified with Medicare. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are Medicare certified providers that can provide the services. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This provider is not a certified 
Medicare provider, and this is a contractual requirement. Therefore, we decided that the Plan does not have to 
pre-approve thirty (30) mental health counseling visits to be provided by a provider not certified with 
Medicare.
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for the ambulance transportation (A0427, A0425). We decided that the 
Plan does not have to pay for the oxygen supplies (A0422).  
 
You asked the Plan to pay for the ambulance transportation (A0427, A0425). You say that you would like 
reconsideration because these services were medically necessary and billed with an appropriate diagnosis code. 
The Plan says that this claim was not billed with an appropriate diagnosis code. 
 
We decided that the Plan has to pay for the ambulance transportation (A0427, A0425).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
coverage criteria have been met. Specifically, there are no Medicare rules that apply to specific diagnosis code 
requirements for ambulance services in this state. The Plan has not forwarded any evidence to support why the 
diagnosis codes billed are not appropriate. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan has not substantiated their denial so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the ambulance transportation (A0427, A0425).  
 
We also decided that the Plan does not have to pay for the oxygen supplies (A0422). 
 
The Plan follows Medicare rules. Medicare rules say that payment under the ambulance fee schedule includes 
oxygen and supplies. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
criteria for coverage have not been met. Specifically, oxygen and supplies are included in the payment for the 
ambulance services and are not separately billable. Therefore, we decided that the Plan does not have to pay for 
the oxygen supplies (A0422). 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LINX Reflux Management System. 
 
You asked the Plan to pre-approve the LINX Reflux Management System. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the LINX Reflux Management System is not 
covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of LINX procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the LINX Reflux Management System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a raised toilet seat is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botulinum toxins (Botox, Dysport, Xeomin and 
Myobloc), will be considered medically reasonable and necessary when administered for treatment of certain 
FDA-labeled indications and Off-label indications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Botox is not not FDA-approved or 
sufficiently supported in high quality evidence to be generally used to treat gastroparesis, although it is an off-
label use. Therefore, without sufficient support made in currently available studies, this request for Botox will 
be considered not medically necessary 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.