Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second-opinion, treatment, tests, and follow-up care 
with an out of network (OON) provider. 
 
You asked the Plan to pre-approve a second-opinion, treatment, tests, and follow-up care with an OON 
provider. You say that the requested OON facility provides dramatically superior health care to urology 
patients. The Plan denied your request. The Plan says there is appropriate care available within the Plan in 
urological oncology, medical oncology, radiation oncology, and palliative care. The Plan says that there is no 
medical need for an OON referral. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a second-opinion, treatment, tests, and 
follow-up care with an OON provider. Our reviewer says that the criteria for coverage of OON care have not 
been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering 
adequate care to meet the enrollee's medical needs through referral to the in-network doctors the Plan has 
referred you to. Early prostate cancer is common and can be treated by the majority of urologists. There is 
nothing unique about your condition that would make it medically necessary to see the requested OON 
provider. Nothing about your needed care warrants a higher tertiary level of care provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a second-opinion, treatment, tests, and follow-up care with an OON provider 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a second-opinion, 
treatment, tests, and follow-up care with an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supply (code K0553) billed 
for date of service October 7, 2021. 
 
You asked the Plan to pay for K0553. You say that you have provided all of the documentation that you have.  
You requested records from the patient's doctor, but they refused. The Plan denied your request. The Plan says 
the records do not support the item billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for items to be covered by Medicare, the 
patients medical record must contain sufficient documentation of the patients medical condition to 
substantiate the necessity for the type and quantity of items ordered and for the frequency of use or 
replacement.  In this case, no medical records were provided to show the patient's medical condition.  In 
addition, the prescription you provided dated April 29, 2021, indicates that the doctor ordered one unit of 
K0553 monthly for the patient.  However, the packing slip for the items in dispute indicates that two units of 
K0553 were delivered to the patient.  There is no explanation as to why a unit in excess of the prescription was 
provided.  Furthermore, your claim for this item indicates a date of service of October 7, 2021. However, your 
packing slip is dated October 6, 2021, and therefore does not match the claim you submitted. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of K0553 have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor supply (code K0553) billed for date of service October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that the CGM is needed. The Plan denied your 
request. The Plan says the enrollee is not using insulin at least three times per day. 
 
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. The Plan requested medical records for the enrollee and asked the number of 
insulin administrations used per day. The physician did not submit records and did not answer the question 
about number of insulin administrations. There is conflicting evidence between office personnel statements, the 
physician's appeal statements, and the Plan's internal information. The appealing provider has failed to support 
that the enrollee requires at least three insulin administrations per day. Based on this information, we decided 
that Medicare rules for coverage of the requested CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM).  
 
If the provider does have evidence that criteria are met, this should be submitted directly to the Plan for 
review.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 14, 2021 
and billed under code 93042.  
 
You asked the Plan to pay for physician services provided to the enrollee. You say that this claim should be 
paid. The Plan denied your request. The Plan says while code 99285 was paid, 93042-59 remains not 
supported. This code is included in codes 23600 and 93010; therefore, it cannot be separately 
reimbursed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate cods. In this case it has been confirmed that code 93042 
was submitted in error as it cannot be separately billed. Therefore, we decided the Plan does not have to pay for 
physician services provided to the enrollee on May 14, 2021 and billed under codes 93042.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (codes A6010 and A6196) provided on date 
of service June 23, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that the patient's inpatient stay was canceled by the 
facility and it was a mistake.  The patient was not an inpatient from June 19, 2020, to June 30, 2020, so this 
claim should be reprocessed. The Plan denied your request. The Plan says the patient was an inpatient on the 
date of service in question, so no separate payment can be made for these items. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies used during a Part A covered stay for 
hospital and skilled nursing facility (SNF) inpatients are included in the inpatient prospective payment system 
(PPS) and are not separately billable. We confirmed that this patient had a billed inpatient stay on the date of 
service in question.  Specifically, the inpatient claim says that the patient was admitted as an inpatient on June 
20, 2020, at 1:59am and remained an inpatient for ten days.  This means that the patient was an inpatient on the 
date of service that the supplies in question in this appeal were provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for medical supplies (codes A6010 and A6196) provided on date of service June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and bitewings 
(D0274) provided by a participating provider on December 8, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and bitewings. You say that you had to go to a 
new in-network provider. The Plan denied your request. The Plan says the benefit limit for D0274 and D0150 
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. The Plan covers a 
comprehensive oral evaluation once every three years and bitewings once every year.   
We looked at the file and Medicare rules. Evidence was provided to show that D0274 and D0150 were 
previously provided on May 3, 2021. Based on this information, we decided that the Plan's rules for coverage 
of a comprehensive oral evaluation and bitewings have already been met. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), and bitewings (D0274) provided by a 
participating provider on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140), and intraoral imaging (D0220) 
provided by an out-of-network provider on December 15, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you would like the 
Plan to pay for this. The Plan denied your request. The Plan says that the benefit limit for D0140 and D0220 
have already been exhausted. 
 
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 Plan has failed to send in evidence to verify that D0140 and D0220 were 
previously provided. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140), and 
intraoral imaging (D0220) provided by an out-of-network provider on December 15, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee has been using the CGM and has 
benefited from this. This should not be discontinued. The Plan denied your request. The Plan says the 
documentation does not support that the criteria are 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 use insulin 
with at least three daily administrations. There are conflicting statements in the record as to whether the 
enrollee is using insulin, the number of injections, and the method of dose adjustments. However, the progress 
note submitted to support this request from date of service April 13, 2022, does not have any statement that the 
enrollee uses insulin at all. The rules require that the treating provider document in periodic visits that the 
criteria are met. Based on this information, we decided that Medicare rules for coverage of the CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).  
 
If the provider has objective evidence that the criteria are met that was not yet submitted, this should be sent to 
the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services (95908, 95885, and 95938) provided 
on September 23, 2021. 
 
You asked the Plan to pay for codes 95908, 95885, and 95938. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We 
looked at the file and Medicare rules. In this case, the review shows that codes 95908, 95885, and 95938 were not billed with modifier 26 per Medicare guidelines. Therefore, we decided that the Plan does not have to pay 
for the monitoring services (95908, 95885, and 95938) provided on September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital sign, her lungs were clear, and she was treated for pain. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on May 17, 2021. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 looked at the file and the rules. We find that code 83789 was billed for specimen validity testing. Validity 
testing on urine specimens used for drug testing shall not be separately billed. Therefore, we decided that the 
Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on May 
17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation is not sufficient to support medical necessity. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found per the product's label, 
Octagam is not FDA-approved for the enrollee's diagnosis of chronic inflammatory demyelinating 
polyradiculoneuropathy (CIDP). Octagam 10% is an immune globulin intravenous (human) liquid preparation 
indicated for the treatment of: o Chronic immune thrombocytopenic purpura (ITP) in adults (1.1) and 
Dermatomyositis (DM) in adults. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
September 11, 2021, to September 12, 2021, and from September 12, 2021, to September 16, 2021. 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you thought this would 
all be covered with no out-of-pocket. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $325 
copayment for days 1-5 each time you are admitted for an inpatient hospital stay. The contract also says there is 
a $0 copayment for day 6 to discharge.  
 
The record shows that as of September 30, 2021, you have met your MOOP for the year. You have been asked 
to pay a $325 copayment for a one-day inpatient hospital stay from September 11, 2021, to September 12, 
2021. You have also been asked to pay a total of $915, which is less than the $1,300 copayment for a four-day 
inpatient hospital stay from September 12, 2021, to September 16, 2021 as you had met your MOOP during 
this hospital stay. There is no charge from day 6 to discharge. An inpatient hospital stay falls within the 
Inpatient Hospital Care 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 copayments for an 
inpatient hospital stay provided from September 11, 2021, to September 12, 2021, and from September 12, 
2021, to September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on 
December 4, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that your doctor recommended three cleanings a year due 
to your gums and exposed roots. The Plan denied your request. The Plan says the benefit limit 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 Plan's coverage rules apply in this case. The Plan covers two 
prophylaxis per calendar year. 
 
We looked at the file and Medicare rules. Prophylaxis was previously provided twice with the year. Based on 
this information, we decided that the Plan's rules for coverage of prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory 
(E0673) provided to the enrollee on June 3, 2021. 
 
You asked the Plan to pay for the services. You say that the  explanation of benefits did not give adequate 
information to establish the accuracy of this decision The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. 
 
The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0675) and accessory (E0673) 
provided to the enrollee on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is weaker and not at her prior level 
of function. You say that the enrollee is now using a mechanical lift for transfers. The Plan denied your request. 
The Plan says SNF care is not medically reasonable and necessary. 
 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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is not shown 
to have an acute decrease in function. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs can, as a practical 
matter, be provided at a lower level of care. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient procedure 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 
an outpatient procedure to be provided by an out-of-network (OON) provider.