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

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided July 8, 
2021. 
 
You asked the Plan to pay for the diagnostic service. You say that this claim denied as duplicate in error. Please 
process the claim for reconsideration per contract guidelines. The Plan denied your request. The Plan says 
exact duplicate claim/service. 
 
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 71045 is radiologic examination, chest. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, the records show that this 
service was previously approved and paid on check dated August 1, 2021. Based on this information, we 
decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiologic examination, chest (71045) provided July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on January 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the provider has reported inpatient hospital services with the incorrect DRG 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 853 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH MCC). 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 services. Our reviewer says that the services at issue in this case were supported by the medical 
records. Our physician reviewer found the review has determined that the records support the use of DRG 853 
in this case. In the presence of incomplete support for sepsis 3, code A41.51 (sepsis due to Escherichia coli), 
R65.20 (severe sepsis without septic shock), and N17.9 (acute kidney failure, unspecified) were removed from 
the claim and diagnosis code K35.32 (acute appendicitis with perforation and localized peritonitis, without 
abscess) was sequenced as principal diagnosis consistent with documentation received. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided to the enrollee on January 23, 2021.  
 
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 foot orthotics (L3020). 
 
You asked the Plan to pre-approve the foot orthotics. You say that the shoe inserts are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable supplies billed with code A0382 billed by an 
ambulance company for date of service December 21, 2021. 
 
You asked the Plan to pay for the disposable supplies. You say that you were seen at an urgent care clinic and 
had a hip fracture.  An ambulance was called to transport you for surgery.  You were not given a choice about 
this transport. The Plan denied your request. The Plan says this code is not payable by Medicare. 
 
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 find that CPT code A0382 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code A0382 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the disposable supplies have not been met. Therefore, we decided that the Plan does not have to pay for disposable supplies billed with code A0382 billed by an ambulance company for date of service 
December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rapid COVID-19 testing (U0002) provided November 7, 
2021. 
 
You asked the Plan to pay for the rapid COVID-19 testing. You say that you had COVID tests before going on 
your cruise. But when you presented your negative test results at check-in you were told the tests were 
supposed to be for 2 days prior or else you could not get on board. The Plan denied your request. The Plan says 
Medicare does not pay for COVID-19 testing for traveling. 
 
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 rapid COVID-19 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the rapid COVID-19 testing (U0002) provided November 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor and supplies 
coded as A9278, A9276 and A9277 
 
You asked the Plan to pre-approve Dexcom G6 CGM and supplies. You say that you are appealing the denial 
of the requested DEXCOM supply receiver, sensor and transmitter. The enrollee needs the item to monitor 
blood sugary and chemical body hormone that regulates the sugar in the blood system. The Plan denied your 
request. The Plan says the records do not support that the enrollee meets the criteria for the requested Dexcom 
G6 CGM and supplies. 
 
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, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Dexcom G6 CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor and 
supplies coded as A9278, A9276 and A9277
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services (97110, 97112, 97140). 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this service is non-covered when provided by a 
Chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy services (97110, 97112, 97140).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a breast ultrasound, tomosynthesis, and diagnostic 
mammogram performed on July 8, 2021. 
 
You asked the Plan to waive the coinsurance for the ultrasound, tomosynthesis, and mammogram. You say that 
the services should have been covered. The Plan denied your request. The Plan says that the correct 
coinsurance was applied. 
 
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 $0 copayment for diagnostic mammograms.  
 
The Plan says you must pay a 20% coinsurance for the ultrasound, tomosynthesis, and mammogram. Based on 
the Plan contract, however, you cannot be asked to pay more than a $0 copayment for diagnostic 
mammograms. Therefore, we decided that the Plan has to waive the coinsurance for a breast ultrasound, 
tomosynthesis, and diagnostic mammogram performed on July 8, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiofrequency ablation provided on November 24, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Radiofrequency ablation. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and the member's PCP 
did not refer for services. 
 
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 Radiofrequency ablation provided on November 
24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the laboratory testing was ordered by the 
referring provider because it was medically necessary, and you would like the claim reprocessed for payment. 
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 February 3, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies to be 
rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor and supplies to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was medically necessary and was 
ordered by the treating provider for the enrollee. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization or a referral from the 
enrollee's primary care physician. 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 March 24, 
2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 8,2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you received no services relating to 
this bill. The Plan denied your request. The Plan says you have been charged to correct cost sharing amount. 
 
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 $90 
copayment for an emergency room visit.  
 
The medical record shows you received services during the ER visit on January 8, 2022. You have been asked 
to pay the allowed amount of $69.01, which is less than the $90 copayment for an ER visit. An ER visit falls 
within the Emergency 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 an 
emergency room (ER) visit provided on January 8,2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy services provided from 
January 4, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayments for the psychotherapy services. You say that you received a letter 
stating all copayments would be waived before starting treatment. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $25 
copayment for each individual or group mental health visit.  
 
The file shows that the Plan ended cost share waivers effective December 31, 2020. Therefore, you have been 
asked to pay a $25 copayment for each of the psychotherapy services.  The file shows a total of 38 visits from January 4, 2021, to December 27, 2021, for a total of $950 ($25 
copayment x 38 visits = $950). The psychotherapy services fall within the Outpatient Mental Health 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 copayments for psychotherapy services 
provided from January 4, 2021, to December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystostomy tube change provided on 
February 2, 2022. 
 
You asked the Plan to waive the copayment for the cystostomy tube change. You say that the service should be 
considered a follow-up to the initial placement of cystostomy system and there should be no cost share. The 
Plan denied your request. The Plan says you have been charged to correct cost sharing amount. 
 
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 $35 
copayment for in-network diagnostic procedures and tests.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$35 copayment for the cystostomy tube change. A cystostomy tube change 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 the cystostomy tube change provided on February 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve Fasenra. You say that the enrollee qualifies for this drug. The Plan denied 
your request. The Plan says the enrollee does not have an accepted indication for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Fasenra. Our reviewer says that the 
requested use of Fasenra is not supported. Our physician reviewer found there is no documentation that Fasenra 
is approved or accepted for use in asthma without evidence of an eosinophilic phenotype. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Fasenra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (E1028, K0108, 
K0823). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the records show the power wheelchair is 
primarily for community use outside the home, and is therefore not covered. 
 
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 power wheelchair and accessories (E1028, K0108, K0823).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computerized tomography (CT) Scan on 
October 25, 2021. 
 
You asked the Plan to waive the coinsurance for a computerized tomography (CT) Scan. You say that you do 
not have money for this. The Plan denied your request. The Plan says the cost share applied 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 20% 
coinsurance up to $75 per day for a computerized tomography (CT) Scan. The total allowed amount of the 
computerized tomography (CT) Scan is $132.75, resulting in a coinsurance amount of $26.55. 
 
You have been asked to pay 20% coinsurance up to $75 per day for a computerized tomography (CT) Scan. A computerized tomography (CT) Scan 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 coinsurance for a computerized 
tomography (CT) Scan on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve Xiidra. You say that Xiidra is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical 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 pre-approve Xiidra 5% drops.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.