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

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic 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. 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. Your treating physician did not submit supporting record to show 
whether you meet Medicare criteria for a therapeutic CGM. The Plan made attempts to obtain supporting 
medical records, but they were not provided. Without this information, we cannot determine whether you meet 
criteria for a therapeutic CGM. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of gastrostomy tube, percutaneous, under 
fluoroscopic guidance including contrast injection (49440), and moderate sedation services (99152, 99153) 
provided on May 12, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the insertion of gastrostomy tube, percutaneous, under 
fluoroscopic guidance including contrast injection (49440), and moderate sedation services (99152, 99153) 
provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 83789 provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this code is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 83789.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the neurology services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as there are 
providers in-network who can provide the same level of care. 
 
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 
neurology services 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 the excision of a mass on your jaw. 
 
You asked the Plan to pre-approve the excision of a mass on your jaw. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is considered a dental service and is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the excision of a mass 
on your jaw.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antigen therapy services provided on February 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the antigen therapy services. You say that you have been seeing this provider for 
20 years and you have been stable on the current treatment. You say changing providers would disrupt your 
care, health, and well-being. The Plan denied your request. The Plan says the provider was out-of-network, and 
no prior authorization was obtained. 
 
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 did not pre-approve the 
antigen therapy services. We found no exception that would require the Plan to pay for the antigen therapy 
services. The records provided for review do not show that the services at issue were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the antigen therapy services provided on February 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
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 transportation. You say that your only method of transportation to 
your dialysis appointments is this benefit. You also say that you have no one that can provide you 
transportation. The Plan denied your request. The Plan says you have exhausted the established benefit for 36 
one-way trips. 
 
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 36 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 stance flexion feature (L5845) for an OttoBock knee 
unit (3R60) and Multiaxial ankle with dorsiflex (L5968). 
 
You asked the Plan to pre-approve the prosthetic equipment. You say that this equipment is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says these items cannot be 
covered per Medicare rules. 

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 rules say that L5968, L5982, L5984, L5985, 
L5986, L5988, L5990 are additional features and/or functions that do not describe a complete prosthetic foot 
and may be used in combination with L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, 
L5981, and L5987. 
 
We looked at the file and Medicare rules. Specifically, L5845 is not considered an approved code for the base 
knee unit that was approved in this case. In addition, L5968 has been requested without L5970, L5971, L5972, 
L5974, L5975, L5976, L5978, L5979, L5980, L5981, or L5987. Therefore, since a complete prosthetic foot has 
not been requested, this will be denied. Based on this information, we decided that Medicare rules for coverage 
of the prosthetic equipment have not been met. Therefore, we decided that the Plan does not have to pre-
approve stance flexion feature (L5845) for an OttoBock knee unit (3R60) and Multiaxial ankle with dorsiflex 
(L5968).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames (V2020), bifocal lens (V2200), anti-
reflective coating (V2750), and sales tax (S9999) provided on October 29, 2021. 
 
You asked the Plan to pay more for the glasses and sales tax. You say that you have not received a check for 
2021. You also say that you would have remembered cashing the check and the Plan would have record of the 
canceled check. The Plan denied your request. The Plan says this second reimbursement is not allowed because 
it exceeds the benefit limit. 
 
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 offers a $150 eyewear allowance per year. 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a $150 reimbursement for 
eyewear provided on February 3, 2021. Based on this information, we decided that the Plan's rules for coverage 
of the glasses and sales tax have not been met. Therefore, we decided that the Plan does not have to pay more 
for the frames (V2020), bifocal lens (V2200), anti-reflective coating (V2750), and sales tax (S9999) provided 
on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 7, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were not informed that refractions are not 
covered. The Plan denied your request. The Plan says this service is not eligible for payment. 
 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.  
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of age-related nuclear cataract, bilateral. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction (92015) provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the claim. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient hospital stay is about to end, and you 
need therapy. The Plan denied your request. The Plan says the enrollee's current medical stability and lack of 
medical complexity, there is no need for physician supervision 3 times per week for the ongoing management 
of any active or acute exacerbation of chronic medical conditions. The enrollee's current level of function, the 
enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. The enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a skilled nursing 
facility, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of septic arthritis of the knee. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
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 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (98943) provided on 
April 11, 2022, and April 14, 2022. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you have chiropractic 
coverage. The Plan denied your request. The Plan says the service received is explicitly excluded; therefore, the 
service is not covered by the plan as an additional benefit. 
 
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 pay for chiropractic manipulative treatment (98943) provided on April 11, 2022, and 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $345.65 copayment for wound care from January 18, 
2022, to March 8, 2022. 
 
You asked the Plan to waive the $345.65 copayment for wound care. You say that you should only be 
responsible for a $35 specialist copayment. The Plan denied your request. The Plan says you are responsible to 
pay a $345.65 copayment. 
 
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 $350 
copayment for in-network Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers.  
 
You have been asked to pay a $1036.95 ($345.65 x 3 = $1036.95) copayment for wound care. Wound care falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. Of note, the record indicates that you received these services at 
a wound care clinic. Wound care clinics are considered outpatient hospital departments. Your contract with the Plan clearly says that you must pay a $350 copayment for in-network wound care provided in an outpatient 
hospital. However, you have only been asked to pay $345.65 which is less than the $350 copayment. 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 $345.65 copayment for wound care from January 18, 2022, to March 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 March 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 March 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic maintenance therapy. 
 
You asked the Plan to pre-approve chiropractic maintenance therapy. You say that you need the maintenance 
chiropractic care to get your back and legs in working order. The Plan denied your request. The Plan says 
chiropractic maintenance therapy is not considered to be medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic maintenance therapy. Our 
reviewer says  the rules say that Medicare does not cover chiropractic maintenance care. Our physician 
reviewer found that in this case the record indicates that you were receiving chiropractic care for cervical and 
lumbar pain.  Our physician reviewer found that the records state you completed active treatment and are 
entering the maintenance therapy phase. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic maintenance therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic maintenance therapy.