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

 
We decided that the Plan does not have to pay for the durable medical equipment (E0745, A4595, and A9901) 
billed for date of service May 4, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were medically appropriate and 
necessary. The Plan denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS are only covered under certain medical 
indications.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (E0745, A4595, 
and A9901) billed for date of service May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical x-rays (D0220, D0230) provided on 
October 27, 2022. 
 
You asked the Plan to pay for intraoral - periapical x-rays (D0220, D0230). You say that this service was not 
authorized by you. You also say this is the first time you have paid a copayment for a regular maintenance teeth 
cleaning. The Plan denied your request. The Plan says there is no coverage for these services. 
 
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. 
 
 
  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 intraoral - 
periapical x-rays (D0220, D0230) provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86333 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 86333. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 86333 is not supported in the medical record. Specifically, code 86333 is not a valid 
CPT code and has no CPT Code Manual definition or payment amount. Based on this information, we decided 
that Medicare rules for coverage of procedure code 86333 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 86333 billed for date of service July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve various power wheelchair accessories (E1020, E2607, 
E1007, E2311, E2313, E2377, E2361, E1028, E0955, E1012). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have medical need for multiple power options included with 
the wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not use intermittent catheterization. While the enrollee has bilateral hip 
and knee flexion contractures, the clinical documentation does not support that the enrollee needs to lie 
backwards. It is noted that the enrollee is at high risk for development of a pressure ulcer, but the clinical 
documentation does not support that power tilt is not enough. Bed to wheelchair transfers and wheelchair to 
commode transfers are independent. The clinical documentation does not support that the enrollee is unable to perform a functional weight shift. It is not medically necessary to control the power options through a joystick 
over the power wheelchair's own switches. The shoulders, elbows, wrist, and hand have 4-5/5 strength. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve various power wheelchair accessories (E1020, E2607, E1007, E2311, E2313, E2377, 
E2361, E1028, E0955, E1012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arthrocentesis, aspiration and/or injection without ultrasound 
guidance and methylprednisolone acetate injection provided on March 04, 2022. 
 
You asked the Plan to pay for Arthrocentesis, aspiration and/or injection without ultrasound guidance and 
methylprednisolone acetate injection. You say that you are appealing the claim payment denial. 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 Arthrocentesis, 
aspiration and/or injection without ultrasound guidance and methylprednisolone acetate injection provided on 
March 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 19, 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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
March 21, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are 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 1 for CPT code(s) 88360 and 88381. 
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) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure codes 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 88305, 88312, 88311, 
and 87101 provided on September 30, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 88305, 88312, 88311, and 87101. You say 
that you are appealing the claim payment denial. 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 laboratory services 
billed under codes 88305, 88312, 88311, and 87101 provided on September 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on June 17, 2022, to July 1, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on June 17, 2022, to July 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 22, 2022, 
to March 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of August 26, 2021, was received on August 13, 2022. Therefore, we decided that the Plan does not have 
to pay for the home health services provided from February 22, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 10, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.   
 
Records show that you do not 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 pre-approve foot orthotics.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on August 15, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for these services based on Medicare criteria. Therefore, we decided that the Plan has to 
pay for the ambulance services provided on August 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy provided on January 08, 2022. 
 
You asked the Plan to pay for colonoscopy. You say that you are appealing the claim payment denial. 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 colonoscopy provided 
on January 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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. 
 
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 dental 
services on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist visit provided on October 17, 
2022. 
 
You asked the Plan to reduce the copayment for a specialist visit. You say that you are reducing the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors 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 reduce the copayment for a specialist visit provided on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the elective total 
shoulder arthroplasty (CPT code 23472). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 
23472 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan 
states the procedure is currently approved as an ambulatory procedure and there is no documentation provided 
to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee 
experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the surgery may be safely performed with a 48-hour observational stay. 
Inpatient admission is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the elective total shoulder arthroplasty 
(CPT code 23472).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation MAKOplasty 
(CPT code 20985). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of MAKOplasty for robotic assistance in 
the setting of total joint arthroplasty has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found robotic assisted total joint surgery has not been shown to be better than conventional open 
surgery. It is not needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted surgical navigation MAKOplasty (CPT code 20985).