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 a Freestyle Libre CGM. 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 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 99292 provided on August 27, 
2021. 
 
You asked the Plan to pay for procedure codes 99291 and 99292. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is Critical care, 
evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List 
separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the records 
provided contain no progress notes for the August 27, 2021, date of service to verify how much time was spent 
providing services to the enrollee. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 99291 and 99292 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99291 and 99292 provided on August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for liver paracentesis procedures provided 
from December 14, 2021, to May 31, 2022. 
 
You asked the Plan to waive the copayment for liver paracentesis procedures. You say that this is a lifesaving 
procedure that you need until you can receive a liver transplant. These copayments are so expensive to cover. 
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 $350 
copayment for 2021, and a $325 copayment for 2022 for outpatient hospital services ($325 x 15 visits = $4875 
+ $350 copayment for December 14, 2021 = $5225).  
 
You have been asked to pay a $5225 total copayment for liver paracentesis procedures. This item/service falls 
within the outpatient hospital 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 liver paracentesis procedures provided from 
December 14, 2021, to May 31, 2022.
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. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 currently is ventilated with acute respiratory failure. The record indicates 
that the enrollee still requires acute care services. The enrollee does not require services at the LTACH that are 
not available at the acute care setting where they are currently receiving care. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on April 19, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis rendered on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (73502) provided on June 20, 
2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges. 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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $76.40 copayment for the x-ray, which is less than the standard $100. 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 an x-ray (73502) provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology service provided on 
June 7, 2022. 
 
You asked the Plan to waive the copayment for diagnostic radiology service. You say that you had these scans 
in the past and did not have to pay this much. 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 $325 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $325 copayment for diagnostic radiology service. This item/service falls within the 
Medicare-covered diagnostic radiology services that are not ultrasounds. 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 diagnostic radiology service provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) and intraoral imaging (D0220) 
provided by an out-of-network provider on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary for you. 
The Plan denied your request. The Plan says your annual maximum dental allowance amount 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, certain limitations apply. The record 
shows your annual maximum dental allowance amount was exhausted on date of service February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3330) and intraoral imaging 
(D0220) provided by an out-of-network provider on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on August 12, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you couldnt see your primary care 
doctor so you had to go to urgent care so you shouldnt have to pay the higher fee. 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 $40 
copayment for Office visits to other providers. 
 
You have been asked to pay a $40 copayment for office visit. This item/service falls within the Office visits to 
other providers 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 office visit provided on 
August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccine services provided on August 22, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the vaccine services. You say that no one told you that you needed prior 
authorization for the service that was rendered. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the vaccine services provided on August 22, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service March 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 16, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
family took you to the closest hospital because you were experiencing stroke symptoms. The Plan denied your 
request. The Plan says you received paramedic intercept services, and were not transported to the nearest 
appropriate facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
March 29, 2022, to April 29, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you shouldnt have 
to pay for this since your cardiologist didnt order it for you. 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 Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 Durable medical equipment provided on March 29, 2022, to April 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for review and interpretation of a wearable 
mobile cardiovascular device provided on February 15, 2022. 
 
You asked the Plan to waive the copayment for review and interpretation of a wearable mobile cardiovascular 
device. You say that you already paid a $20 copayment for the heart monitor and you dont know who this 
provider is. 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 
copayment for Outpatient diagnostic procedures or tests.. 
 
You have been asked to pay a $20 copayment for review and interpretation of a wearable mobile 
cardiovascular device. This item/service falls within the Outpatient diagnostic procedures or tests. 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 review and interpretation of a wearable mobile 
cardiovascular device provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), polarization (V2762), 
and polycarbonate or equal lens (V2784) provided on March 31, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, polarization, and polycarbonate or equal lens. You say 
that you would like to be reimbursed up to the total amount of the expense or the total amount allowed by your 
policy for these lenses. The Plan denied your request. The Plan says these lenses are not covered. 
 
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 standard lenses including single vision, lined bifocal, lined trifocal, lenticular, and 
Tier I (standard) progressive lenses. 
 
 
 We looked at the file and the Plan's rules. The record shows that the lenses you received were enhanced lenses 
that are not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of 
the anti-reflective coating, polarization, and polycarbonate or equal lens have not been met. Therefore, we 
decided that the Plan does not have to pay for the anti-reflective coating (V2750), polarization (V2762), and 
polycarbonate or equal lens (V2784) provided on March 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neurology services provided on June 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the neurology services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent 
or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the neurology services provided on June 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 20, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that the appellant is requesting reconsideration stating that 
provider sent in specimen to them. The Plan denied your request. The Plan says the enrollees network primary 
care physician (PCP) or plan must give the enrollee approval in advance before they can use providers not in 
the plan's network. This is called giving you a "referral." 
 
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 lab testing provided on June 20, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
(74183) provided on June 10, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you 
disagree with the charges. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  The enrollee has been asked to pay a $200 copayment for the MRI. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for magnetic resonance imaging (MRI) (74183) provided on June 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 24, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance came because you were short of breath and had chest tightness. You also say that you were advised 
you did not need to go to the hospital. The Plan denied your request. The Plan says you were not transported to 
the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 24, 2022.