Persius/hicric huggingface dataset:
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 continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued oxygen concentrator rental. 
 
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 request exceeds the 36 month rental limit. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The file shows that you have had the oxygen concentrator rental for 
more than 36 continuous months. 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 continued 
oxygen concentrator rental.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections. 
 
You asked the Plan to pre-approve Botox injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the enrollee has failed any anticholinergic 
medications. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is indicated for the treatment of overactive 
bladder in patients who have an inadequate response to or are intolerant of an anticholinergic medication. 
 
We looked at the file and Medicare rules. The submitted records do not document that the enrollee has had an 
inadequate response to or is intolerant of an anticholinergic medication. Based on this information, we decided 
that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Botox injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 23020 and 23430 billed for date of service 
January 13, 2022. 
 You asked the Plan to pay for procedure codes 23020 and 23430. You say that you have provided records to 
support the services at issue. The Plan denied your request. The Plan says payment for codes 23020 and 23430 
is bundled into payment for code 23472. 
 
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 
23020 and 23430 are column II codes to column I code 23472. This claim has not been billed with appropriate 
modifiers 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 23020 and 23430 billed for date 
of service January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) 
received on April 12, 2022, from an out-of-network (OON) provider. 
 You asked the Plan to pay for deluxe frames and progressive lenses. You say that you thought the items would 
be covered. The Plan denied your request. The Plan says services with an out-of-network provider 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 these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of deluxe frames and progressive lenses have not been met. Specifically, the services were rendered 
with an out-of-network provider, and not covered. Therefore, we decided that the Plan does not have to pay for 
deluxe frames (V2025) and progressive lenses (V2781) received on April 12, 2022, from an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bacterial filters (E1399). 
 
You asked the Plan to pre-approve bacterial filters. You say that your records state that a non-invasive 
ventilator is required by the enrollee and is included in this request. The enrollee does need supplies to ensure 
the proper operation of the machine. The Plan denied your request. The Plan says Medicare does not cover 
ventilator supplies separately. The cost of the filter is bundled into the ventilator monthly rental.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Ventilator filters are not covered separately in the frequent and 
substantial servicing payment category. Based on this information, we decided that Medicare rules for coverage 
of bacterial filters have not been met. Therefore, we decided that the Plan does not have to pre-approve 
bacterial filters (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 2, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not a covered benefit. 
 
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 pay for self-administered drugs provided 
on April 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 3, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 3, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 01, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. 
 
 
 
 You have been asked to pay a $50 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery on April 01, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the patient is autistic and needs to be alerted to 
hyperglycemia. The Plan denied your request. The Plan says the patient does not meet criteria for a CGM 
because records show the patient does not administer insulin three or more times a day nor are they on a 
continuous subcutaneous insulin infusion pump. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CGM. Our reviewer says that the 
patient does not meet criteria for a CGM. Our physician reviewer found although the patient has diabetes, they 
are only treated with 70/30 insulin twice per day. Therefore, the patient does not meet all of Medicare's 
coverage criteria for this item. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis, 51 or greater genes 
(81455) provided December 12, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the FoundationOneHeme was ordered by the 
treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 
are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the targeted genomic sequence analysis, 51 or greater genes (81455) provided December 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 17, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider should not be required 
to obtain authorization. The Plan denied your request. The Plan says the provider was out-of-network. There 
was no prior authorization, and the services were 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 subsequent nursing facility care provided on 
March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation, including 
cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device 
(25513). 
 
You asked the Plan to pre-approve the T-12 Kyphoplasty. You say that you have done all of the conservative 
measures before turning to surgery. The procedure is needed as soon as possible. The Plan denied your request. 
The Plan says the enrollee has not pursued full conservative measures and does not meet guideline 
requirements. 
 
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 T-12 Kyphoplasty. 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 radiographic evidence that the T12 fracture is less than 12 weeks old. 
 
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 T-12 Kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the percutaneous vertebral augmentation, including cavity creation (fracture 
reduction and bone biopsy included when performed) using mechanical device (25513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. More research is needed to show safety 
and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's provider requested this test 
and you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no 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 December 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram (ECG) provided on 
February 2, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that the provider billed with the improper 
code and the copayment should be waived. The Plan denied your request. The Plan says the proper copayment 
was applied for the service that was rendered. 
 
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 $110 
copayment for basic radiological services in an outpatient hospital.  
 
  You have been asked to pay a $110 copayment for an ECG. an ECG 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 an echocardiogram (ECG) 
provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the approved bed is not 
appropriate for the enrollee. A total electric bed is medically necessary. The Plan denied your request. The Plan 
says the requested item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a psychiatric telehealth visit provided on 
May 31, 2022, and June 14, 2022. 
 
You asked the Plan to waive the coinsurance for a psychiatric telehealth visit. You say that you should not have 
to pay such a large coinsurance. The Plan denied your request. The Plan says the coinsurance that was applied 
was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for individual session for mental health specialty. The allowed amount of this visit is $176 
resulting in a $35.20 coinsurance ($176 x 20% = $35.20). You had two visits, totaling $70.40 ($35.20 x 2 = 
$70.40). 
 
You have been asked to pay a $70.40 coinsurance for a psychiatric telehealth visit. A psychiatric telehealth 
visit falls 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 for a psychiatric telehealth visit 
provided on May 31, 2022, and June 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service, advanced life support, 
emergency transport provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that it would be a hardship for 
you to pay all of the ambulance bill and would like a reduction. The Plan denied your request. The Plan says 
the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for In-Network Emergency Ambulance.  
 
You have been asked to pay a $290 copayment for the ambulance service. The ambulance service falls within 
the Ambulance 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 ambulance 
service, advanced life support, emergency transport provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home-delivered meals. 
 
You asked the Plan to pre-approve the home-delivered meals. You say that you feel that this should be covered 
as it was recommended by the heart failure nurse after an emergency room visit. The Plan denied your request. 
The Plan says this benefit is only covered for enrollees after an inpatient hospital stay. The enrollee was seen in 
the emergency room which is not considered inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that meal delivery is not covered by Medicare. The 
Plan offers a supplemental benefit which covers home-delivered meals only after an inpatient hospital stay due 
to congestive heart failure. 
 
We looked at the file and Medicare rules. The enrollee was not in an inpatient hospital stay prior to this 
requested. Based on this information, we decided that Medicare rules for coverage of the home-delivered meals 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home-delivered meals.