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

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM) receiver and sensor (K0553 and K0554). 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 CGM receiver and sensor. You say that it is your 
medical opinion that the enrollee is an excellent candidate for a Libre 2. The Plan denied your request. The 
Plan says the enrollee is not checking their sugars and they are only on basal insulin. The Plan also says that 
there is no evidence that the enrollee has tried and failed traditional glucose monitoring. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
 
  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 FreeStyle Libre 2 CGM receiver 
and sensor. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer 
found the enrollee does have diabetes mellitus. Our reviewer found that the enrollee is not insulin treated with 
three or more daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion 
pump. Our physician reviewer also found that the enrollee's insulin treatment regimen does not require frequent 
adjustment by the beneficiary on the basis of blood glucose monitor or CGM testing 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 FreeStyle Libre 2 CGM receiver and sensor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM) receiver and sensor (K0553 and K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided September 20, 
2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011 
 
We looked at the file and Medicare rules. Payment for these services is included in payment to the ESRD 
facility. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (82728, 83540, 83550) 
provided September 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) provided on December 1, 2021. 
 
  You asked the Plan to pay for the psychotherapy (90832). You say that services were rendered to the patient in 
good faith and the medical records clearly reflect the medical necessity of the services. You say that the claim 
should be processed for payment. The Plan denied your request. The Plan says the provider must attempt to 
consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy (90832) have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for psychotherapy (90832) 
provided on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0553) provided 
November 8, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Additionally, the dates of service is before the date of 
delivery. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, 
K0553) provided November 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fluoroscopic guidance and localization of needle or 
catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003) provided on 
September 9, 2020 
 
You asked the Plan to pay for code 77003. 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. In this case, we have confirmed that code 77003 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic 
or therapeutic injection procedures (77003) provided on September 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the eyeglasses (V2020, V2202, V2750, 
V2783) purchased on August 26, 2021, following cataract surgery. 
 
You asked the Plan to waive the coinsurance for the eyeglasses. You say that this provider is in-network, and 
you paid for these eyeglasses up front. You understand that the services coded with V2799 are not covered and 
that you are responsible for those, but you expected the other services to be covered in full with a $0 
copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your 
coinsurance was assessed in accordance with your contract. The provider in this case is not part of the Plan's 
network, which means that you are responsible for 50% coinsurance on the allowed cost for these services. 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 50% 
coinsurance for eyewear (post cataract surgery) received from an out-of-network provider.  
 
Documentation shows that you paid a total of $319.90 for the covered eyewear components. The Plans 
allowed cost for these services is $204.90. This is the maximum amount that the Plan would pay for these 
services, and this is the amount that is used to calculate coinsurance. The difference between the amount you 
paid and the Plans allowed cost for these services is not your responsibility, but it also is not the responsibility 
of the Plan. When you use your insurance information at the time of purchase, this amount is written off as a 
discount. The Plan can tell contracted (in-network) providers to refund this amount to you directly, but the Plan 
cannot tell out-of-network providers to refund this amount. You may be able to ask the provider to refund you 
this amount directly. 
 
Documentation shows that this provider is out-of-network with your Plan. While the additional information you 
sent to us did include a printout of a provider search which includes the provider in question, the top right 
corner of that page does not reflect the information for your specific medical network with the Plan. This 
information is insufficient to show that this provider is in-network with your specific plan. 
 
You have been asked to pay 50% coinsurance for the eyeglasses. The Plan reimbursed you $102.47, which is 
50% of the Plans allowed cost for these services. This means that you have been reimbursed 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 
the eyeglasses (V2020, V2202, V2750, V2783) purchased on August 26, 2021, following cataract surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool or bench (E0245). 
 
You asked the Plan to pre-approve the tub stool or bench. You say that you need this equipment because you 
do not have any balance, and this can prevent you from falling. The Plan denied your request. The Plan says 
this service is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81227, 81401, 81225, 81226) provided 
November 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were billed for a single genetic testing panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81227, 81401, 81225, 81226) 
provided November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says they have confirmed with the 
ordering provider that there was no order for genetic testing made for the enrollee. 
 
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 laboratory services provided on 
September 21, 2021, have been met. Specifically, no documentation from the ordering provider was included to 
indicate the medical necessity of the rendered services. Furthermore, the provider confirmed they did not order 
the testing services when these records were requested. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on September 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 23, 2020, to November 30, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the available records in the case file 
do not support that the enrollee had shortness of breath while lying flat. 
 
We looked at this coder's review, the file, and Medicare rules. 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 skilled nursing facility (SNF) services provided to the enrollee from November 23, 2020, to 
November 30, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria (J1602) and the administration (96413). 
 
  You asked the Plan to pre-approve Simponi Aria and the administration. You say that the enrollee is in 
desperate need of help now, and her rheumatologist suggested Simponi Aria because he has had success 
treating with this medication. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products and has not tried any of the preferred agents. The Plan also says that 
the provider did not provide a rationale for use of the non-preferred product for safety or efficacy. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Simponi Aria and the administration. 
Our reviewer says that Simponi Aria is not medically reasonable and necessary. Our physician reviewer found 
the Plan requires a trial of drugs Humira, Enbrel, Xeljanz or Rinvoq before they will approve the requested 
drug. Our reviewer found that you have not tried and failed the required drug(s). Our physician reviewer also 
found that there is no documentation provided indicating that the Plans required drug(s) would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria and the administration have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Simponi Aria (J1602) and the administration (96413).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that the 
requested drug is not medically reasonable an necessary. Our physician reviewer found the enrollee has a 
diagnosis of Exudative age-related macular degeneration, right eye, with active choroidal neovascularization. 
In this case, the Plan requires a trial of Avastin before they will approve the requested drug. The case file does 
not contain documentation of trial and failure of Avastin. In addition, the documentation does not support that 
Avastin would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from 
September 15, 202, to October 14, 2021. 
 You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
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 the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) admission provided from September 15, 202, to October 14, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay the claim under the in-network benefit for an inpatient admission 
provided from November 4, 2021, through November 6, 2021. 
 
You asked the Plan to pay the claim under the in-network benefit for an inpatient admission. You say that this 
was a transfer to an out-of-network hospital due to a bed diversion at an in-network hospital because of 
COVID-19. The Plan denied your request. The Plan says the claim processed 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 50% 
coinsurance for Inpatient Hospital Care, Out-of-Network.  
 
You have been asked to pay 50% coinsurance for an inpatient admission. The inpatient admission falls within 
the Inpatient Hospital Care, Out-of-Network 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 pay the claim under 
the in-network benefit for an inpatient admission provided from November 4, 2021, through  
November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 23, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says prior authorization was not 
obtained for these services rendered by an OON provider. 
 
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 the laboratory services provided on July 23, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle lite test strips.

You asked the Plan to pre-approve Freestyle lite test strips. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that the rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands).

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 Freestyle lite test strips. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no reason given why this brand (Freestyle lite specifically) is needed. Hence, coverage for this brand which is a non-preferred brand is not deemed medically necessary according to the plan criteria provided. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle lite test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle lite test strips.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the you do not treat with insulin 
three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).