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 (K0554, K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the 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 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 (K0554, K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for an oncologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for an oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve OneTouch Ultra test strips. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for 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 diabetic testing supplies that cannot be provided by preferred 
providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has preferred brands 
available that can provide the items at issue in this appeal. The documentation does not support the enrollee has 
tried and failed or has a limitation precluding the preferred diabetic testing supply products. 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 OneTouch Ultra test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 87634 is bundled into payment for code 87631. 
 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 87634 
is a column II code to column I code 87631. 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 procedure code 87634 billed for date of service January 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cataract surgery. 
 
You asked the Plan to pre-approve the cataract surgery. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the cataract surgery have been met. 
There were no medical records submitted for review.. Therefore, we decided that the Plan does not have to pre-
approve the cataract surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the contact lenses (V2531) purchased on January 10, 
2022. 
 
You asked the Plan to pay more for the contact lenses. You say that the enrollee was prescribed these medically 
necessary contact lenses in order to combat their severe dry eye syndrome, and resolve their worsening eye 
pain, tearing, and blurred vision. You also say that the $1,200 amount is unaffordable for the enrollee. The Plan 
denied your request. The Plan says this claim processed correctly, and in accordance with the enrollee's 2022 
Evidence of Coverage booklet. The Plan also says that the enrollee was reimbursed $100 towards the purchase 
of these contact lenses, leaving them with a total responsibility of $1,100.00. 
 
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 up to a $100 maximum benefit for eyewear every 2 calendar years. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that the total cost for these contact 
lenses was $1,200.00. The Plan reimbursed the enrollee the full $100 maximum benefit, and the enrollee's 
eyewear allowance has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay 
more for the contact lenses (V2531) purchased on January 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from an acute inpatient rehab 
facility. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee can get the services they need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has no active comorbidities and does not require continued inpatient 
hospitalization during rehabilitation for close medical motoring.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that an IRF admission is not 
medically necessary, and the enrollee can receive the care they need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee has complex functional impairments with a hip fracture and knee injury. The enrollee 
has both active comorbidities and hospital complications requiring multiple interventions. The enrollee requires 
continued inpatient hospitalization during rehabilitation for close medical monitoring and can tolerate intense 
therapy." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 2, 2022. 
 
You asked the Plan to pay for the testing services. You say that the documentation substantiates the claim. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 The file shows that pharmacogenomics panel testing was provided. We find that the panel was not billed with a 
single code as required. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on June 27, 
2022. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that you had a similar procedure 
done before and werent charged so you shouldnt be now. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Outpatient procedures and services. 
 
You have been asked to pay a $50 copayment for outpatient procedure. This item/service falls within the 
Outpatient procedures and 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 
outpatient procedure provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee on June 7, 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 was not reported with condition code G0. 
 
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 procedure codes G0402, G0404, and G0463 are not supported in the medical record. Specifically, 
this claim should have been reported with condition code G0. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on 
June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on May 18, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was not for preventative care. The 
Plan denied your request. The Plan says the test should be billed under a single code. 
 
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, there are insufficient medical records from the treating physician to show the testing was ordered 
for a covered clinical indication. We find that the testing was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing services provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 11, 2022. 
 
You asked the Plan to pay for the panel testing. You say that the test was medically necessary. The Plan denied 
your request. The Plan says the test should be billed under a single code. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on March 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you were unaware that the 
physician was out-of-network. You also say that the physician did nothing to help your symptoms. The Plan 
denied your request. The Plan says services performed by an out-of-network provider are not covered. The Plan 
also says that the services can be provided in-network. 
 
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 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 the office visit (99213) provided on March 10, 2022, by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need 
transportation for routine dermatology appointments. The Plan denied your request. The Plan says you have 
exhausted your transportation benefit. The Plan also says your benefit plan does not cover more than 10 one-
way trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
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 items are medically necessary. The Plan denied 
your request. The Plan says the member does not require frequent self-adjustment of insulin dosage based on 
the blood glucose testing results. 
 
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 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 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 laboratory services provided on April 29, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 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 laboratory services provided on April 29, 2021, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve the continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not perform blood glucose testing at least four times per day, 
use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on 
the blood glucose testing results 
 
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, or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided 
that the Plan does not have pre-approve the continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an office visit provided on July 13, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
You have attached documentation and would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 
2022.