Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) reader. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM reader. You say that you are not able to check your 
sugar. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 and 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 a Freestyle 
Libre CGM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) reader.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the endovascular revascularization (37225) provided on November 15, 
2021. 
 
You asked the Plan to pay for the endovascular revascularization (37225). The Plan denied your request. The 
Plan says that procedure code 37225 is not supported by the medical records submitted. 
 
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. Specifically, the Plan has not forwarded any medical records to support their 
denial of procedure code 37225. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for the endovascular revascularization (37225) provided on November 15, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on 
December 14, 2021. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that the diagnosis code billed for the 
service at issue is explicitly identified in the Local Coverage Determination (LCD) as payable. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. The ICD-10-CM has a coding 
convention that requires the underlying condition be sequenced first, if applicable, followed by the 
manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a psychiatric diagnostic evaluation have not been met. Specifically, the claim has been billed with 
F05 as the primary diagnosis code. F05 has a "code first" note meaning that the underlying condition must be 
sequenced first on the claim. Therefore, we decided that the Plan does not have to pay for a psychiatric 
diagnostic evaluation (90792) provided on December 14, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for toenail trimming (code G0127) billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for toenail trimming. You say that this service is covered for the patient's condition. 
The Plan denied your request. The Plan says that Medicare coverage criteria are not met for this service. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records show that these conditions are present. Specifically, you have documented that the patient has 
peripheral vascular disease. The Plan has made no effort to dispute this finding.  The burden is on the Plan to 
prove its denial is correct, and they have failed to do so in this case. Based on this information, we decided that 
Medicare rules for coverage of toenail trimming have been met. Therefore, we decided that the Plan has to pay 
for toenail trimming (code G0127) billed for date of service January 18, 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 lab services (80053, 82378, 85025, 36415, G0463) provided 
on February 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (80053, 82378, 85025, 36415, G0463) provided on February 
11, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient initial observation services provided to the enrollee on 
February 1, 2022 and February 2, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records support payment. The Plan denied 
your request. The Plan says that this procedure is not covered by Medicare. 
 
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. The plan has not substantiated their denial in this case. There appear to be 22 
different codes at issue in this case. The plan has denied the claim saying "this procedure is not covered by 
Medicare" without specifying which procedure is not covered. Saying that a single procedure is not covered is 
not sufficient for a case with so many different services at issue. Therefore, we decided that the Plan has to pay 
for inpatient initial observation services provided to the enrollee on February 1, 2022 and February 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on March 17, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you received a 
medical eye refraction for the diagnosis of Age-related nuclear cataract, bilateral (per the office). Eye 
refractions are only covered by your Plan if performed by a participating vision provider and performed as a 
routine screening. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services (76641-RT) provided on January 11, 
2022. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not indicate two 
separate services were performed. 
 
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. In this case, the documentation does not support payment for an 
additional unit of code 76641-RT beyond what has been already paid. Based on this information, we decided 
that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound services (76641-RT) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on December 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99442 is not supported. 
 
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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the file shows that the 
services were performed within 7 days of a previous evaluation and management service from the same 
provider. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth services rendered on 
December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
December 2, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0673, E0675) provided December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00811) provided May 20, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that this claim is for the services of an anesthesiologist 
while the other claim was for the certified nurse anesthesiologist. They each provided distinct services. Your 
provider contract stipulates that you bill and receive payment for both. The Plan denied your request. The Plan 
says duplicate of a claim processed, or to be processed 
 
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 00811 is anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified. 
 
We find that CPT code 00811 is not supported in the medical record. Specifically, the records show that this 
same service, for this enrollee was paid on check dated 10/25/2021. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services (00811) provided May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on January 28, 2022. 
 
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 this service is not covered by Medicare. 
 
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 received 
on January 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 6, 2022, to January 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that since you already were 
admitted in the hospital for the same incident before it should be covered. The Plan denied your request. The 
Plan says the copayment 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 $290 
copayment per day for days 1 through 6, starting with day 1 each time you are admitted. 
 
 
 
 You have been asked to pay a total of $1,160.00 copayment for your inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient 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 inpatient hospital stay provided from January 6, 2022, to January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for an office visit on December 28, 2021.
  
You asked the Plan to waive the $45 copayment for an office visit on December 28, 2021. You say that you 
only had a COVID test and no other services were rendered. The Plan denied your request. The Plan says you 
must pay a $45 copayment for each covered office visit for urgently needed services. 
 
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 $45 
copayment for Urgently Needed Services.  
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for office visit. In your appeal you stated you only received a 
COVID test and were never seen by an actual physician. Please note records submitted support the charge for 
an office visit. An office visit falls within the Urgently Needed 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 $45 copayment for an office visit on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
4, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you believe this charge 
should be covered because this was a follow up visit from being hospitalized. The Plan denied your request. 
The Plan says the copayment 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 $35 
copayment for a specialist office visit.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist 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 specialist office visit provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) and the 
hearing services (V5299) provided on October 27, 2016. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these 
items/services were rendered by an out of network provider, without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids/services only when rendered by a network provider.  
 
 
 
 
 
 
 
 
 We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the hearing aids/services in this case were 
rendered by an out-of-network (OON) hearing care vendor. Therefore, we decided that the Plan does not have 
to issue reimbursement for the hearing aids (V5298 x 2) and the hearing services (V5299) provided on  
October 27, 2016.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ER visit, and an office visit provided 
from June 19, 2021, to June 23, 2021. 
 
You asked the Plan to waive the copayments for ER and office visits. You say that these visits should be 
covered because they should of all been taken care in the first visit. The Plan denied your request. The Plan 
says the copayments are 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 $90 
copayment for the ER visit and a $5 copayment for the office visit.  
 
 You have been asked to pay a total of $95 copayment. ER visits fall within the Emergency care benefit 
category and 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 copayments for an ER visit and an office visit provided from 
June 19, 2021, to June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $350 copayment for carpal tunnel surgery performed on 
December 9, 2021. 
 
You asked the Plan to waive your $350 copayment for carpal tunnel surgery performed on December 9, 2021. 
You say that you had the same surgery on September 17, 2020, and you didn't have to pay a copayment. The 
Plan denied your request. The Plan says you pay $350 per day for outpatient procedures and services 
performed in an outpatient hospital or ambulatory surgical center. 
 
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 $350 
copayment for Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
 You have been asked to pay a $350 copayment for carpal tunnel surgery. Carpal tunnel 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 your $350 copayment for carpal tunnel 
surgery performed on December 9, 2021.