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

 
We decided that the Plan does not have to pay for a Continuous Glucose Monitoring system (CGM) 
 
You asked the Plan to pay for the Continuous Glucose Monitoring System. 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 they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Continuous Glucose Monitoring System have 
not been met. Therefore, we decided that the Plan does not have to pay for a Continuous Glucose Monitoring 
system (CGM)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for code 87801. You say that this service was necessary and is supported as billed. 
The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 87801 is Infectious agent by nucleic acid (DNA or RNA), 
multiple organisms; amplified probe technique.  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 87801. Our reviewer says that code 87801 is not 
supported by the medical record. Our reviewer found the laboratory report describes multiple infectious agent 
detection; however, these services would be included in code 87798, which was already reimbursed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87801 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87801 billed for date of service July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soundgear hearing aids. 
 
You asked the Plan to pre-approve Soundgear hearing aids. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Medicare does not cover hearing aids; however, the 
Plan has supplemental coverage for hearing aids if obtained by a Plan hearing aid provider. 
 
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 only when provided through the Plans in-network hearing aid provider. Based on this 
information, we decided that the Plan's rules for coverage of Soundgear hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Soundgear hearing aids.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided on August 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for injection services. You say that the reports attached support the services 
provided. The Plan denied your request. The Plan says there is no referral or authorization on file for the 
services provided. 
 
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 injection services provided on August 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 13, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be billed for a 
services that was not rendered because the physicians assistant did not know how to operate the machine. 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 $10 
copayment for physician/practitioner service. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner service benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office 
visit provided on September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from June 26, 2022, to July 8, 
2022. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says this request is 
unable to be approved because you have not paid upfront in full for the services rendered. The Plan also says 
medical records are to determine the specifics of your care to determine if they qualify as a medical emergency 
and to determine if qualifies, the allowable contracted rate for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 inpatient services have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts 
requesting this information, but it was not received. Without medical records, we are unable to determine if the 
services provided qualify as a medical emergency. Additionally, the submitted records do not show that you 
paid for the services up front and in full, which is required by the Plan. It appears you have only made a partial 
payment of $5,000. Therefore, we decided that the Plan does not have to pay for the inpatient services provided 
from June 26, 2022, to July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Ozempic is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 22, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
claim was submitted to the Plan for payment on August 25, 2022, exceeding the 12 months claim submission 
limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until August 25, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
August 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision of a benign lesion up to 1.25 cm (D7410). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the excision 
of a benign lesion up to 1.25 cm (D7410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral - periapical 
each additional radiographic image (D0230) x4, resin-based composite - one surface, anterior (D2330) x6 and 
resin-based composite - one surface, posterior (D2391) x3 provided on September 2, 2022, to September 17, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was out-of-
network until the claim was denied. You say you should not be responsible for paying this claim. 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. This benefit includes the 
requested comprehensive oral evaluation but is limited to on procedure code every three calendar years, 
intraoral - periapical each additional radiographic image but is limited to one procedure code per calendar year 
and resin-based composite - one surface, anterior or posterior but is limited to two procedure codes per 
calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D0150 and D0230 x4 were exhausted on date of service December 14, 
2021, and D2330 x6 and D2391 x3 were exhausted on date of service September 2, 2022. Therefore, we 
decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral - periapical 
each additional radiographic image (D0230) x4, resin-based composite - one surface, anterior (D2330) x6 and 
resin-based composite - one surface, posterior (D2391) x3 provided on September 2, 2022, to September 17, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 24, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says a 
claim must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 
calendar year, after the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until September 27, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on  
May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitors (CGM) 
 
You asked the Plan to pay for the continuous glucose monitors (CGM). 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 they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitors (CGM) have not 
been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitors (CGM)
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 21, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were billed with the 
correct code. The Plan denied your request. The Plan says despite several attempts, we did not receive the 
pertinent information describing findings on comprehensive physical exam, VS, oxygen saturation, 
electrolytes, CXR report, ECG abnormalities, members response to units of PRBC administered, decision 
making of high complexity, and counseling and/or coordination of care with other physicians. The submitted 
information is not sufficient to determine the appropriate level of care reimbursement above what was already 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 emergency department visit have 
been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided 
on May 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (D9440) and comprehensive oral evaluation 
(D0150), or pay more for the problem focused limited oral evaluation (D0140), four periodontal scalings and 
root planings (D4341 x4), and surgical extraction (D7210) provided on June 16, 2022, and August 14, 2022, by 
an out-of-network (OON) provider. 
 You asked the Plan to pay for the office visit and comprehensive oral evaluation, and to pay more for the 
problem focused limited oral evaluation, scalings and planings, and surgical extraction. You say that you were 
not aware that this treating provider was not in-network. The Plan denied your request. The Plan says the office 
visit is not a covered benefit under your dental plan. The Plan says your benefits for the comprehensive oral 
evaluation have already been exhausted. The Plan also says that you are responsible for any charged amount 
above the Plans cost-sharing amount for covered services when your services are received from an OON 
provider. 
 
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, office visit (D9440) is not among those 
covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one 
procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) 
on December 23, 2021, and your comprehensive oral evaluation (D0150) benefit has been exhausted. You have 
also been asked to pay a 50% coinsurance for each of the periodontal scalings and root planings (D4341 x4) 
and surgical extraction (D7210), plus difference between the out-of-network providers charges and the Plans 
payment for these services and the problem focused limited oral evaluation (D0140). 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 pay for the office visit (D9440) and comprehensive oral evaluation (D0150), or pay more for 
the problem focused limited oral evaluation (D0140), four periodontal scalings and root planings (D4341 x4), 
and surgical extraction (D7210) provided on June 16, 2022, and August 14, 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 an occlusal guardhard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal  
guardhard appliance, full arch (D9944).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 22, 2021. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
November 22, 2021.