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

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500, A5513) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
diabetic shoes and inserts (A5500, A5513) 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 pay for therapeutic parenteral drug, single administration (D9610) 
provided on July 15, 2022. 
 
You asked the Plan to pay for the therapeutic parenteral drug, single administration (D9610). You say that this 
service was denied and it is clearly covered in your plan. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
therapeutic parenteral drug, single administration (D9610) provided on July 15, 2022.
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 September 
14, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. 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. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. 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 September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on February 2, 2022, to April 22, 2022. 
 
You asked the Plan to pay for a CGM. You say that a CGM was medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 a CGM have not been met. Therefore, we decided 
that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on February 2, 
2022, to April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a porcelain/ceramic crown (D2740) for teeth numbers 7 and 8 provided 
on June 15, 2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740) for teeth numbers 7 and 8. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says that this provider is a non-
contracted provider. The Plan also say that with the information they have, they cannot determine how you 
came to the servicing provider, or whether the services are medically necessary. 
 
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. The Plan covers a 
porcelain/ceramic crown (D2740) for teeth numbers 7 and 8 when the services are medically necessary and 
reasonable. 
 
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 a porcelain/ceramic crown (D2740) for teeth 
numbers 7 and 8. Our reviewer says that this meets criteria. Our physician reviewer found the documentation 
provided meets the criteria for coverage for crown restorations (D2740) for teeth numbers 7 and 8 to provide 
adequate function due to the significant coronal breakdown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain/ceramic crown (D2740) for teeth numbers 7 and 8 have been met. 
Therefore, we decided that the Plan has to pay for a porcelain/ceramic crown (D2740) for teeth numbers 7 and 
8 provided on June 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and the periodontal maintenance (D4910) provided on August 31, 2022.

You asked the Plan to pay for the gingival irrigation (D4921). You say that you are appealing this claim. You say the Plan was waiting for a periodontal history from your dentist before making the payment. The Plan denied your request. The Plan says the service was 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 Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) and the periodontal maintenance (D4910) provided on August 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on May 18, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that the service provided to the enrollee is not 
related to the reason why the enrollee is in hospice. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on May 3, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for initial hospital care 
provided on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 26, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. 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 surgery provided on 
August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (U0003, U0005) provided on July 22, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was submitted to support this claim. 
 
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 lab testing have been met. No 
clinical records were provided to support this request. Only lab results were submitted for review. Therefore, 
we decided that the Plan does not have to pay for lab testing (U0003, U0005) provided on July 22, 2022.
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 September 
5, 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 8 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 September 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided on 
May 27, 2022 and June 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as prior 
authorization was not obtained. 
 
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 record shows that prior authorization was not obtained for the chiropractic services provided in this case. 
Additionally, these services were rendered by an out-of-network provider. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatments (98941) provided on May 27, 2022 and  
June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2022. 
 
You asked the Plan to pay for lab services. You say that you were unaware that the lab was out-of-network, and 
feel you should not have to pay. 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 
May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 22, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 testing provided on 
June 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on August 29, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the medical records provided support the need for the ambulance transport. The Plan 
denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance service, basic life support, 
emergency transport and ground mileage. Our reviewer says that the transportation via ambulance from the 
enrollee's dialysis appointment to the assisted living facility was not medically necessary.  Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van, private care, tax) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport and ground mileage provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient procedure provided on July 07, 2022. 
 
You asked the Plan to pay for an outpatient procedure. You say that our staff state we are in-network, please 
review claim again. 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 an outpatient procedure 
provided on July 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on May 1, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that you are asking for a reconsideration with supporting medical records which highlight the 
medical necessity. The Plan denied your request. The Plan says the ambulance transport was not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance service, basic life support, 
emergency transport and ground mileage.  Our reviewer says that the transportation via ambulance from the hospital to the enrollee's residence was not 
medically necessary. Our physician reviewer found the enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private care, taxi) 
without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport and ground mileage provided on May 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a follow up visit provided on July 28, 2022. 
 
You asked the Plan to pay for a follow up visit. You say that we depend on the facility staff to verify eligibility 
and to obtain authorization. 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 a follow up visit 
provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on August 17, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that you were told that this provider was in-network. 
This 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 a specialist visit 
provided on August 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing services 
 
You asked the Plan to pre-approve the continued home health skilled nursing services. You say that the 
medical records provided support the need for the requested continued home health skilled nursing services. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continued home health skilled 
nursing services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the provided records do not document any acute or unstable medical conditions or injuries or 
changes in medication or treatment which would necessitate any further skilled nursing visits beyond what 
have already been approved. The records indicate the enrollee has been educated on her disease process and 
medications. No medical notes form the enrollee's treating physician are provided documenting an order or 
need of additional skilled nursing services. 
 
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 continued home health skilled nursing services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued home health skilled nursing 
services