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

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM), a 
non-preferred brand. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
Furthermore, if the enrollee did meet criteria, the Plan's preferred brand is the Freestyle Libre system. 
 
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 has not had an in-
person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment 
plan within the last 6 months. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM), a non-preferred brand.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a knee athroplasty and an inpatient hospital 
stay provided from September 13, 2021, to October 1, 2021. 
 
You asked the Plan to waive the copayment for the knee athroplasty and inpatient hospital stay. 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 $325 
copayment per day for days 1-6 of Inpatient hospital care and a $290 copayment for Outpatient hospital 
services. 
 You have been asked to pay a $1,300 copayment for four days of inpatient hospital care and a $290 copayment 
for the knee arthroplasty. the knee athroplasty falls within the outpatient hospital care 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 a knee athroplasty and an inpatient hospital stay provided 
from September 13, 2021, to October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy services provided on May 3, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this 
procedure is inclusive to the main procedure. 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 49321 is laparoscopy, surgical; with biopsy (single or 
multiple). We find that CPT code 49321 is not separately reportable. Therefore, we decided that the Plan does 
not have to pay for the laparoscopy services provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral drugs dispensed in office (D9630) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve oral drugs dispensed in office. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the requested dental work 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve oral 
drugs dispensed in office (D9630) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 17, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you have not had to pay anything before. 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 $10 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $10 copayment for an office visit. 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 an office visit provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on June 8, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing (G0483) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 2) and pontic (D6245). 
 
You asked the Plan to pre-approve fixed bridge. You say that not having the bridge work would cause shifting 
of your teeth. You say this could cause more damage. You say that fixed bridge work is preventive in that the 
shifting of your teeth without it will lead to more work in the future. The Plan denied your request. The Plan 
says fixed bridge is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6740 x 2) and pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2784, V2303, V2781, V2304, V2750) 
provided on November 22, 2021. 
 You asked the Plan to pay for the eyeglasses. You say that the providers office told you that you still had 
allowance available for 2021, even though you ordered eyewear from the same office in January 2021. The 
Plan denied your request. The Plan says you previously exhausted your vision benefit for the 2021 calendar 
year in January. Your benefit covers up to $100 per year for routine eyewear, and you have exceeded this 
amount in 2021. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to $100 per calendar year. 
 
We looked at the file and the Plan's rules. Documentation shows that you previously purchased eyeglasses on 
January 4, 2021, and used your full benefit allowance at that time. Based on this information, we decided that 
the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses (V2784, V2303, V2781, V2304, V2750) provided on November 22, 2021.  
 
Your complaint about potential misinformation from a Plan-contracted provider 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on October 22, 
2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this testing is considered 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 pay for the Guardant360 testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no role to use Guardant360 to assess minimal residual disease. 
Guardant360 will not impact or direct treatment. 
 
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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing (81479) provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special anesthesia service (code 99100) provided on June 9, 
2021. 
 
 
You asked the Plan to pay for special anesthesia service. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
code 99100 is always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment and if 
it is covered, payment for it is subsumed into the payment for services to which it is incident.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of special anesthesia service have not been met. Therefore, we decided that the Plan does not have to 
pay for special anesthesia service (code 99100) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ROMTech Portable Connect Adaptive 
Rehabilitation Device with data capture and remote treatment function. 
 
You asked the Plan to pre-approve the device. You say that the prescribed equipment will aid in the 
symptomatic relief of pain. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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. This item is 
considered exercise equipment. Therefore, we decided that the Plan does not have to pre-approve the 
ROMTech Portable Connect Adaptive Rehabilitation Device with data capture and remote treatment function.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure memory mattress for the enrollee. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a mattress is covered only where a hospital bed is 
medically necessary. 
 
There is no evidence that the enrollee has a hospital bed for this requested mattress. Based on this information, 
we decided that Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a dry pressure memory mattress for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 12. 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary in order to have 
your crown replaced. The Plan denied your request. The Plan says core build up is not a covered service. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric hospital bed (E0303). 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says your weight does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the enrollee's weight is between 350 and 600 pounds. 
 
Your weight is outside the range for this bed. Based on this information, we decided that Medicare rules for 
coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
bariatric hospital bed (E0303).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Gemtesa for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this claim should be paid. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on November 4, 2021, by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on May 31, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says emergency services provided by a non-contracted 
provider were not necessary for your condition. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary 
or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We decided that this case does not meet prudent layperson criteria for emergency care. A prudent layperson 
would not reasonably expect the absence of immediate medical care to seriously jeopardize their health in this 
case. Without more specific medical records, we cannot confirm the services met the criteria for emergency 
care. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on 
May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-assessment and intervention of medical nutrition therapy 
with an individual patient for each 15 minutes (97803). 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the provider is a registered 
dietician specialist whose counseling services were necessary for this enrollee. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for coverage for the services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
 
 
 
 Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for re-assessment and intervention of medical nutrition therapy with an individual 
patient for each 15 minutes (97803).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee had a recent syncopal episode that 
required emergency care, and multiple medical issues that puts her at increased risk for falls. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee so 
the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from the enrollee's primary care physician 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 laboratory services provided on September 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on 
November 13, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on this date. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the ultrasound of the abdomen (76705) provided on November 
13, 2021.