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

 
We decided that the Plan does not have to waive the copayment for the tendon sheath incision provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for the tendon sheath incision. You say that the Plan should cover 
more of the surgery. 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 $325 
copayment for each Medicare-covered visit to an ambulatory surgical center for services.  
 
You have been asked to pay a $325 copayment for the tendon sheath incision. This item/service falls within the 
outpatient surgery, including services provided at 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 the tendon sheath incision provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile dermatologist to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve mobile dermatologist. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
mobile dermatologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures and need a 
replacement. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 25, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73030-26-LT billed for date of service 
September 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim is not a duplicate. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim. 
 The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that code 73030 was reimbursed by the Plan on 
September 24, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed service was provided twice on the same date. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 73030-26-LT billed for date of service September 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the enrollee has exhausted the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 26, 
2022, through March 26, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological exam and refraction 
provided on October 5, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmological exam and refraction. You say that you 
were told that the services would be covered. You say you told the provider that you only wanted what 
insurance would cover. 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 diagnostic eye exams.  
 
You have been asked to pay a $50 copayment for the ophthalmological exam and refraction. The 
ophthalmological exam falls within the vision care benefit category. The medical record shows a diagnosis of 
cataracts which makes the eye exam medical in nature. Please note, you were not charged for the refraction. 
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 ophthalmological exam and refraction 
provided on October 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a PET scan provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you are not paying the PET scan 
copayment that was performed incorrectly. 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 $250 
copayment for each advanced imaging services.  
 
 
 
 You have been asked to pay $250 copayment for a PET scan. This item/service falls within the outpatient 
diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a PET scan provided on 
August 24, 2022.  
 
Your complaint about being required to pay for a service that was done incorrectly is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freespira (A9279, A9291). 
 
You asked the Plan to pre-approve Freespira. You say that you have tried several medications to treat your 
post-traumatic stress disorder (PTSD). You say that they were not effective. You say that you had transcranial 
magnetic stimulation (TMS) therapy which was not effective either. You also say that you feel you have 
exhausted your treatment options and need this to be approved. The Plan denied your request. The Plan says 
the requested item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Freespira have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freespira (A9279, A9291).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member would benefit from an IRF admission. 
The Plan denied your request. The Plan says the member is medically stable and does not have complex 
medical issues. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical needs are too 
medically complex for a lower level of care. The Plan denied your request. The Plan says admission to an 
LTACH is not to be used as an alternative to completion of the full course of treatment in the referring hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating the medical necessity for 
admission to an LTACH. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested service is 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 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 proton beam therapy. 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 compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity-modulated radiation therapy/image-guided radiation 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has failed skilled nursing 
facility (SNF) placement and the home plan is not safe. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 10060 billed for date of service April 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the procedure code is billable and correct. The 
Plan denied your request. The Plan says that a modifier should be considered. 
 
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 10060 was billed with 23, an emergency department place of service code. The 
physician who performs the emergency room service bills for the surgical procedure without a modifier. Based 
on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 10060 billed for date of service April 8, 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: 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 you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for a CGM. 
 
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 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 the gene panel testing provided on April 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that the clinical utility of the testing is validated. 
The Plan denied your request. The Plan says it is not appropriate to bill individual codes for a single 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. 
 
 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 testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 03, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you had to come back a 
different day which is why there was this copayment. 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 $5 
copayment for outpatient laboratory tests. 
 
You have been asked to pay a $5 copayment for the laboratory services. This item/service falls within the 
outpatient laboratory tests 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 
laboratory services provided on November 03, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met in a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle 2 continuous glucose monitor (CGM) sensor kit 
(K0553) provided on November 28, 2022. 
 
You asked the Plan to pay for a Freestyle 2 CGM sensor kit. You say that supporting medical records and 
supporting documentation have been submitted to request reconsideration of the denied claim. The Plan denied 
your request. The Plan says the date of service for the CGM does not match the delivery date, shipping date or 
the date the label was created. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The records show that the date of service of November 28, 2022, does not match the delivery date, shipping 
date or the date the label was created. Medicare rules say that all services that do not have appropriate proof of 
delivery (POD) from the supplier will be denied. If the supplier utilizes a shipping service or mail order, the 
POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the 
beneficiary. Therefore, we decided that the Plan does not have to pay for a Freestyle 2 continuous glucose 
monitor (CGM) sensor kit (K0553) provided on November 28, 2022.