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

 
We decided that the Plan does not have to pre-approve a Freestyle 2 Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. The Plan denied your request. The Plan says the enrollee does not 
require insulin three or more times daily. 
 
 
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 a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 2 Libre 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device 
billed for date of service September 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is an accepted procedure code. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 record does not contain valid proof of delivery for the date of service at issue. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device billed for date of 
service September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve evaluation and management service. You say that you need to go to a closer 
facility. You say that the transportation service is unreliable. You also say that your trips keep getting 
cancelled. The Plan denied your request. The Plan says the enrollee's medical group is no longer contacted with 
the requested facility. The Plan says the requested service can be provided in network. The Plan also says 
 
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 confirmed there are 
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 office visit to be provided by an out-of-network (OON) provider.  
 Your complaint about the Plans transportation service not being reliable 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 o pre-approve a pneumatic compression device (PCD) (E0652). 
 
You asked the Plan o pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says a PCD coded as E0652 used to treat lymphedema not 
extending onto the chest, trunk and/or abdomen is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard 
compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week 
trial. Therefore, we decided that the Plan does not have o pre-approve a pneumatic compression device (PCD) 
(E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart for 
plaque. 
 
You asked the Plan to pre-approve the CT scan. You say that the coronary calcium scan was ordered by your 
physician after having a heart attack. The Plan denied your request. The Plan says quantitative calcium scoring 
is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan of the heart for plaque is not medically necessary. Our physician reviewer found that the enrollee had 
a heart attack. CT coronary calcium score was ordered following the heart attack. However, CT coronary 
calcium scoring as a screening tool is not indicated in this clinical situation as it would not effectively change 
the treatment. CT calcium testing is indicated when someone without a history of coronary artery disease is at a 
moderate level of risk and the decision for cholesterol medication or other aggressive treatments needs to be 
decided. The CT coronary score can help more accurately assess risk. In this case, this enrollee is already at a 
high risk as they already had a heart attack and would be recommended aggressive medical treatment 
regardless of the CT coronary score results. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart for plaque.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Provigil 100mg tablet medication. 
 
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 medication is not a covered 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Provigil 100mg tablet 
medication.  
 
Benefits for this item 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 procedure code 99285 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were reasonable and necessary. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
 We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with vaginal itching and dysuria of 5 days. The enrollee was 
hemodynamically stand and in no acute distress. The records do not show that the severity of problems posed 
an immediate significant threat to life or physiologic function. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99285 billed for date of service August 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to receive daily physician monitoring and interventions. The Plan denied your request. The Plan says 
they will continue to cover acute level care at the current facility. 
 
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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. 
 
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: 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH. 
 
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 the enrollee is improving but is still somewhat unstable and should require only 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
 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 a magnetic resonance imaging (MRI) of the lower 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says there was no change in the enrollee's status showing a need for further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI of the lower extremity is not medically necessary. Our physician reviewer found that the enrollee has right 
knee pain. Physical findings revealed no instability but there was tenderness of medial aspect. X-ray revealed 
minor medial compartment osteoarthritis. MRI of the knee was requested. However, the clinical documentation 
and x-ray results did not reveal a red flag diagnosis or indication for following up with advanced imaging such 
as MRI. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), a 
comprehensive oral evaluation (D0150), intraoral radiographic images (D0210), a cleaning 
(D1110), a crown (D2740), core buildup (D2950), and full mouth debridement (D4355) for tooth 
#14 provided by an out-of-network provider on October 11, 2022, October 31, 2022, and 
November 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should cover all 
dental services up to the annual maximum of $2,000. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. Also, the denial of payment for the core 
buildup and full mouth debridement is correct because they are not covered by the Plan. 
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the 
Plans payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The core buildup and full mouth debridement are not covered under the Plans dental 
benefit. Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation 
(D0140), a comprehensive oral evaluation (D0150), intraoral radiographic images (D0210), a 
cleaning (D1110), a crown (D2740), core buildup (D2950), and full mouth debridement (D4355) 
for tooth #14 provided by an out-of-network provider on October 11, 2022, October 31, 2022, and 
November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22015 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were not related. The Plan denied 
your request. The Plan says the service is included within the global surgery package of code 22633. 
 
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 payment for CPT code 22015 is not supported. The records in the case file do not show that the 
service was unrelated to previously provided procedure code 22633. Furthermore, modifier 59 appended to the 
code at issue has not been used correctly.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 22015 billed for date of 
service November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail trimming provided on September 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nail trimming. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 nail trimming provided on September 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 29, 2022, to August 27, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary for the enrollee. The Plan 
denied your request. The Plan says by July 29, 2022, clinically the enrollees condition no longer required daily 
skilled services at an inpatient Skilled Nursing Facility (SNF) level of care. The enrollee was clinically stable 
and not in acute distress. 
 
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 pay for 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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pay for SNF care provided from July 29, 2022, to August 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are upset that you were not approved for 
SSBCI benefits. The Plan denied your request. The Plan says that based on the information submitted, there is 
no documentation that you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support that the Plan made multiple attempts to obtain 
medical records from the provider for this case. The records also show that an attestation was provided 
showing you meet the criteria for coverage. This means that the Plan has not provided a valid reason for 
denying payment of the SSBCI benefits. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services provided by an in-network 
provider on August 23, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you believe that you were billed 
in error. 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 $40 
copayment for in-network laboratory tests provided at an outpatient hospital facility. 
 
You have been asked to pay a $10.20 copayment for the lab services because the allowed amount for these 
services is less than the $40 copayment. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and supplies 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 lab services provided by an in-network provider on August 23, 2022.