Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for date of service July 23, 
2022 to July 27, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that you believe you are an in-network provider 
and these services should be paid. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
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 S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for date of service July 23, 2022 to July 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on March 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the provider 
did not submit progress notes that are needed in order to determine the clinical utility of the testing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, both the lab report and progress notes are included in the case file. 
As such, the Plan has not provided documentation supporting its denial. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services 
provided on March 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair. 
 
You asked the Plan to pre-approve a transport chair. You say that the records show that the enrollee is unable to 
ambulate more than 5 feet due to sever back pain and weakness. You say that the enrollee's longstanding 
rheumatoid arthritis and her current infection with tuberculosis add to these issues. You say that the enrollee 
requires a transport chair for medical appointments and activities of daily living. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transport chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that the records provided support the need 
for the item in dispute. The Plan denied your request. The Plan says the criteria for coverage 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 Dexcom G6 receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 receiver.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx test billed for date of service 
May 13, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx test. You say that this test should be covered 
because it is supported by clinical evidence and is not available through any other laboratory. The Plan denied 
your request. The Plan says there is no evidence that the patient's treating provider ordered this test. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for any diagnostic test to be covered, it 
must be ordered by the physician who is treating the patient.  In this case, such order appears to be missing.  
Specifically, the Plan contacted the physician who you listed on the claim as the ordering physician.  That 
physician's office confirmed that they did not order this test. Medicare rules state that without a valid order, this 
test cannot be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FoundationOne Liquid CDx test have not been met. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne Liquid CDx test billed for date of service May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you are blind and live alone. The Plan 
denied your request. The Plan says you do not meet the requirements for approval. 
 
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 does not show that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and treatments with a pain specialist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that it is medically necessary for you to 
get your pain treated and there are no in-network providers that can treat your pain. The Plan denied your 
request. The Plan says the requested provider is an OON provider, and the enrollee was directed to an in-
network provider that is within their service area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and treatments with a pain specialist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is not covered under Medicare Part B.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Aranesp as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Aranesp (J0881).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested LDCT will address 
the enrollee's symptoms of concerning malignancy. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. The enrollee is 92 years old. We find that the enrollee does not meet the eligibility criteria of being between the ages of 55 and 77 years old. Therefore, we decided that the 
Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an iv-pole rental provided from July 1, 2021, to 
February 21, 2022. 
 
You asked the Plan to waive the coinsurance for an iv-pole rental. You say that you were not given an iv pole 
during these times. The Plan denied your request. The Plan says that 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 enrollees must pay a 20% coinsurance for durable medical equipment (DME) 
and related supplies.  
 
The Plan says you must pay $11.99 for an iv-pole rental. Based on the Plan contract, however, you cannot be 
asked to pay more than a 20% coinsurance for an iv-pole rental. Therefore, we decided that the Plan has to 
waive the coinsurance for an iv-pole rental provided from July 1, 2021, to February 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing services provided on May 2, 2022. 
 
You asked the Plan to pay for the CxBladder testing services. You say that this procedure was medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this testing is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for 
CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the CxBladder 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder 
testing services provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that each provider needed to evaluate the same 
tooth, and you should not have to pay for the evaluations done on the same tooth. The Plan denied your request. 
The Plan says your benefit for the requested item or service 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 benefit for the requested item or service was exhausted on date of service July 12, 2022. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam and intraoral x-ray (D0150, 
D0210) provided on July 21, 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 your benefit for the requested item or service 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 benefit for the requested item or service was exhausted on date of service June 10, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral exam and intraoral x-ray (D0150, 
D0210) provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83550 billed for date of service April 18, 2022. 
 
You asked the Plan to pay for code 83550. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 83550 is bundled into payment for code 84466. 
 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 83550 
is a column II code to column I code 84466 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 code 83550 billed for date of service April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for prophylaxis (D1110) and bitewing x-rays (D0274) provided on August 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that your benefit for the requested items or services has already 
been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested items or services was 
previously exhausted. Therefore, we decided that the Plan has to pay for prophylaxis (D1110) and bitewing x-
rays (D0274) provided on August 23, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x4) provided on July 19, 2022. 
 
You asked the Plan to pay for the gingival irrigation (D4921x4). You say that you do have a history of 
periodontal scaling. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 gingival irrigation (D4921 x4) are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921 x4) provided on July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayments for the injections and office 
visits provided on July 14, 2022, and August 3, 2022. 
 
You asked the Plan to waive the coinsurance and copayments for the injections and office visits. You say that 
these charges should be covered. 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-covered Part B chemotherapy drugs and other Part B drugs and a $20 copayment for 
each Medicare-covered specialist visit. For July 14, 2022, the total amount charged for the injections was 
$262.07 with a coinsurance of $52.41 ($262.07 total amount x 20% coinsurance). For August 3, 2022, the total 
amount charged for the injections was $262.07 with a coinsurance of $52.41 ($262.07 total amount x 20% 
coinsurance). For each date of service, a $20 copayment was charged for the office visit. The total copayment 
amount for both dates of service was $40 ($20 copayment x 2 visits). The total combined coinsurance was 
$104.82 ($52.41 coinsurance + $52.41 coinsurance). 
 
You have been asked to pay a 20% coinsurance for the injections and a $40 copayment for the office visits. The 
injections fall within the Medicare Part B prescription drugs benefit category. 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 coinsurance and copayments for the injections and office visits provided on July 14, 2022, and 
August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were denied your entitled cleaning because 
you refused to have other procedures performed at your expense. You also say that the x-rays were taken at 
your expense and then the doctor examined your mouth. The Plan denied your request. The Plan says your 
benefit for the requested item or service 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 benefit for the requested item or service was exhausted on date of service July 13, 2022. Therefore, 
we decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and the complete 
lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are a contracted provider with the Plan 
and the enrollee needs a new set of dentures. The Plan denied your request. The Plan says your benefit for the 
requested item or service 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 benefit for the requested item or service was exhausted on the date of service of March 11, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110) and the 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and a periapical first film 
(D0220) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to have these dental 
procedures done. The Plan denied your request. The Plan says your benefit for the requested item or service 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 benefit for the oral evaluation was exhausted on the date of service of February 22, 2022. The 
record also shows your benefit for the periapical first film was exhausted on the date of service of February 24, 
2021. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) and a periapical 
first film (D0220) provided on June 7, 2022.