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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
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 criteria are not 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 treat with 
insulin three or more times per day or use an insulin pump. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate its safety 
and effectiveness. 
 
 
  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) and a power seat elevation feature (E2300) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a 
power seat elevation feature. You say that the requested items are a medical necessity for you. The Plan denied 
your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the requested electrical accessories are not 
medically necessary as you do have use of the upper extremity and can operate and control the power options 
using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Additionally, a power seat elevation feature is non-covered because it is not primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) and a power seat elevation feature (E2300) for a power 
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options and upgraded electronics. 
 
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. Medicare rules say that a Group 3 PWC with multiple power options is 
covered when specific criteria are met. 
 
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 records document that the enrollee 
does not have any pressure injuries to the skin or spasticity. He does not need intermittent bladder 
catheterization that necessitates a power tilt and recline. He has use of the upper extremity and can operate and 
control the power options included in a basic wheelchair. The records do not support that the Group 3 PWC 
with multiple power options is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options and upgraded 
electronics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four bioimpedance spectroscopy (BIS) visits (93702). 
 
You asked the Plan to pre-approve the BIS visits. You say that this procedure is necessary for the enrollee. The 
Plan denied your request. The Plan says this request is not medically necessary, as bioimpedance spectroscopy 
is considered an investigational and experimental procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the BIS visits. Our reviewer says that 
the requested BIS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was diagnosed with breast cancer and underwent a right total mastectomy with left sentinel 
lymph node biopsy. Four BIS visits were requested. Our reviewer found that however, there is currently 
insufficient high-quality evidence supporting this testing method improves outcomes better than the standard 
method of monitoring for lymphedema. Our physician reviewer also found that without sufficient support made 
for this request, the BIS 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 the BIS visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four bioimpedance spectroscopy (BIS) visits (93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic test and durable medical 
equipment provided on June 8, 2022. 
 
You asked the Plan to waive the cost share for diagnostic test and durable medical equipment. You say that you 
are disputing the share cost. 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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of these 
prosthetic devices and supplies total $770.17, resulting in a total coinsurance amount of $154.03. 
 
You have been asked to pay $125 copayment for diagnostic test and durable medical equipment and 20% 
coinsurance for prosthetic devices and related supplies. These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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 share for diagnostic test and durable medical equipment provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for telephone services provided on July 18, 2022. 
 
You asked the Plan to pay for telephone services. You say that after an office visit with your doctor, further 
blood work was necessary to determine if you had iron deficiency. You say that your doctor called you with the 
test results and you thought this telephone call was a follow-up to the office visit. The Plan denied your request. 
The Plan says that this cost sharing was charged correctly because you did not use Teladoc services. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for telephone services that are initiated by a Plan provider.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay for 
telephone services that are initiated by a Plan provider. This means that the Plan did not follow Medicare rules 
for disclosure of cost sharing information. Therefore, we decided that the Plan has to pay for telephone services 
provided on July 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22612 & 63047 billed for date of service 
May 9, 2022. 
 You asked the Plan to pay for procedure codes 22612 & 63047. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for code 22612 & 63047 is bundled into 
payment for code 22633. 
 
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 
22612 & 63047 are column II codes to column I code 22633. 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 codes 22612 & 63047 billed for date of 
service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 3, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
Additionally, the Plan says that the testing was performed at the request of the enrollee. There is no 
documentation stating how this test will directly impact treatment. Screening tests are not covered under 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 3, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urine and blood samples provided on July 
20, 2022. 
 
You asked the Plan to waive the copayment for urine and blood samples. You say that you are disputing the 
share cost. 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $5 copayment for urine and blood samples. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and 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 copayment for urine and blood samples provided on July 20, 2022.  
 Your complaint about redoing the urine sample 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia during a radiological procedure provided on 
August 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia during a radiological procedure. You say that you are requesting the 
medical records to be reviewed and a reconsideration to pay on the denied claim. The Plan denied your request. 
The Plan says an authorization was not obtained prior to 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 anesthesia during a radiological procedure 
provided on August 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 27, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for level 2 hospital subsequent care provided on June 2, 2022. 
 
You asked the Plan to pay for level 2 hospital subsequent care. The Plan denied your request. The Plan says 
National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99233 and 
99232. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with 
this PTP code pair. 
 
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 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for level 2 hospital subsequent care provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (63650) provided on June 10, 
2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this code is not eligible for payment for surgical 
assistant services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 63650. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services (63650) provided on June 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 22, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
claim was denied because the claim was filed past the filing limit. 
 
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 emergency department visit was not filed until March 24, 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 pay for an emergency department visit provided on 
January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician visits via telephone provided from May 12, 2022, 
to June 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician visits via telephone. You say that the services were received prior to 
being notified that your primary care physician was no longer in-network with the plan. The Plan denied your 
request. The Plan says no authorization was obtained prior to 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 physician visits via telephone provided from May 
12, 2022, to June 7, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pool membership provided on January 1, 2022. 
 
You asked the Plan to pay for a pool membership. You say that you submitted the proof of payment. The Plan 
denied your request. The Plan says it was determined that a pool membership is not a covered 
benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the membership is for a qualified health club or fitness facility during the calendar year, covered 
instructional fitness classes, or participation in wellness programs.  
 
 
  The Plans rules for coverage of gym benefits have not been met because The Plan rules say that they 
reimburse you up to $150 per calendar year towards your cost for membership in a qualified health club or 
fitness facility during the calendar year, covered instructional fitness classes, or participation in wellness 
programs. Pool memberships are excluded from this benefit. Therefore, we decided that the Plan does not have 
to pay for a pool membership provided on January 1, 2022.