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

 
We decided that the Plan does not have to pay for the wrist-hand orthosis rendered on March 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the wrist-hand orthosis rendered on 
March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
this service is not medically necessary. 
 
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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not reasonable and necessary. Our physician reviewer found 
there is no neurological exam and no red flag to mandate an immediate MRI of the lumbar spine. There is no 
physical therapy and no plain film report in the records either. Our reviewer also found that medical necessity 
of the requested MRI has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided from March 4, 
2022, to March 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services (99291) provided from March 4, 2022, 
to March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve gastroenterology services. You say that the enrollee's case is very 
complicated and evaluation can only be done by this provider. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the 
enrollee can be treated by an in-network gastroenterology specialist. 
 
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 
gastroenterology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levemir for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Levemir for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat treatment with Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical-necessity rules for the requested drug have 
not been met because the safety and effectiveness of repeat treatments have not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zilretta. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the FDA 
updated the label for Zilretta in 2020 to remove the limitation that the drug is not intended for repeat use and 
modified the label to indicate that the efficacy and safety of repeat administration of Zilretta have not been 
demonstrated. In this case, the requested drug is being used for its current FDA-labeled indication. The FDA 
has not restricted its use to a single time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
repeat treatment with Zilretta (J3304).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service July 11, 
2021. 
 
You asked the Plan to pay for procedure code S9083. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 31, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $30 
copayment for telehealth services at specialist virtual. Covered services include certain telehealth services, 
including services by primary care providers (PCPs) and specialists. 
 
You have been asked to pay a $30 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits 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 office visit on March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a robotic-assisted laparoscopy surgery provided on January 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a robotic-assisted laparoscopy surgery. You say that the receipt requires the 
diagnosis code. You also say you will go personally to request the receipt. The Plan denied your request. The 
Plan says this facility provider is a non-contracted provider with the Plan. 
 
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 a robotic-assisted laparoscopy surgery provided on 
January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
April 24, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the services were 
necessary and should be covered. The Plan denied your request. The Plan says the ambulance benefit is a 
transportation benefit, if no transport occurs, there is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on April 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you are in considerable pain. The Plan denied your 
request. The Plan says you do not meet the criteria. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The file shows that the orthotics were ordered due to osteoarthritis. The records do not show that you suffer 
from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, 
neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the 
Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 11, 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 April 11, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on February 8, 
2022. 
 
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says the provider was not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the ankle foot orthoses, and the 
additions to lower extremity orthoses provided from March 28, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis, the ankle foot orthoses, and the additions to lower 
extremity orthoses. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the services rendered are not a covered benefit. 
 
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 a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include a valid proof of delivery or a delivery ticket to indicate 
the specific supplies rendered. 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 lumbar-sacral 
orthosis, the ankle foot orthoses, and the additions to lower extremity orthoses provided from March 28, 2022, 
to March 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that you would like to continue with physical 
therapy to help with the healing process. The Plan denied your request. The Plan says additional physical 
therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you can transition to an independent home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow brace (L3761) provided on April 11, 2022. 
 
You asked the Plan to pay for an elbow brace. You say that this is supported in the records. The Plan denied 
your request. The Plan says relevant medical records have not been submitted. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. 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 an elbow brace (L3761) provided 
on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic, prophylactic, or diagnostic 
injection; subcutaneous or intramuscular and injection, omalizumab, 5 mg provided on January 26, 2022, and 
February 9, 2022. 
 
You asked the Plan to waive the coinsurance for therapeutic, prophylactic, or diagnostic injection; 
subcutaneous or intramuscular and injection, omalizumab, 5 mg. The Plan denied your request. The Plan says 
the correct cost share was applied to the claims. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
 You have been asked to pay a 20% coinsurance for therapeutic, prophylactic, or diagnostic injection; 
subcutaneous or intramuscular and injection, omalizumab, 5 mg. The therapeutic, prophylactic, or diagnostic 
injection; subcutaneous or intramuscular and injection, omalizumab, 5 mg falls within the Medicare Part B 
Prescription Drug 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 coinsurance for therapeutic, 
prophylactic, or diagnostic injection; subcutaneous or intramuscular and injection, omalizumab, 5 mg provided 
on January 26, 2022, and February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 16, 2022.