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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee was recently hospitalized for uncontrolled 
diabetes. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a 
therapeutic CGM. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services billed with codes 96132, 96133, 96138, 
and 96139 for August 10, 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 procedure codes 96132, 96133, 96138, and 96139 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 96132 is neuropsychological testing evaluation services 
by physician or other qualified health care professional, including integration of patient data, interpretation of 
standardized test results and clinical data, clinical decision making, treatment planning and report, and 
interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. The 
definition of code 96133 is neuropsychological testing evaluation services by physician or other qualified 
health care professional, including integration of patient data, interpretation of standardized test results and 
clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for 
primary procedure. The definition of code 96138 is psychological or neuropsychological test administration 
and scoring by technician, two or more tests, any method; first 30 minutes. The definition of code 96139 is 
psychological or neuropsychological test administration and scoring by technician, two or more tests, any 
method; each additional 30 minutes (List separately in addition to code for primary procedure). 
 
We find that CPT codes 96132, 96133, 96138, and 96139 are not supported in the medical record. Specifically, 
there is no documentation of face-to-face time with the patient or start and stop time to support code 96132. 
Given that primary procedure code 96132 is not supported, add-on code 96133 is also not supported. There is 
no documentation of the start and stop time by the physician to support code 96138. Given that primary 
procedure code 96138 is not supported, add-on code 96139 is also not supported. 
 
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 pay for the testing services billed with codes 96132, 
96133, 96138, and 96139 for August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies rendered on August 1, 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 proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the electrical stimulator supplies rendered on August 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 16, 2022 to 
March 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with an NOA 
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 reviewed the file and the Medicare rules. A valid NOA was not submitted with this claim. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 16, 2022 to 
March 17, 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 14, 2022, 
to March 15, 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 reviewed the file and the Medicare rules. 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 April 20, 2021, was received on April 29, 2022. This date does not match the 
From date of the first period of continuing care in 2022. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from February 14, 2022, to March 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 13, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor (CGM) system. 
 
You asked the Plan to pre-approve a Freestyle CGM system. You say that the enrollee needs to monitor her 
glucose levels regularly but is having trouble with checking finger sticks due to pain and numbness in her 
fingers. With the continuous glucose monitor, she does not have to prick her finer and can maintain good 
glucose control with continuous visualization of glucose levels. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for approval of the requested CGM system. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
continuous glucose monitor (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intrauterine copper contraceptive (code J7300) and insertion 
of IUD (code 58300) provided on August 15, 2022. 
 
You asked the Plan to pay for intrauterine copper contraceptive and insertion of IUD. The Plan denied your 
request. The Plan says these services are not covered by Medicare under any condition. 
 
The Plan contract does not provide coverage for insertion of intrauterine device and birth control pills. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover insertion of intrauterine 
device and birth control pills. Therefore, we decided that the Plan does not have to pay for intrauterine copper 
contraceptive (code J7300) and insertion of IUD (code 58300) provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on October 14, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the records provided support medical 
necessity. 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 the subsequent nursing 
care provided on October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adult forearm walker (cardiac walker) (E1399). 
 
You asked the Plan to pre-approve the walker. You say that the enrollee will benefit in recover with the use of 
an adult Forearm walker (cardiac walker). The Plan denied your request. The Plan says a cardiac walker is not 
covered by Medicare and the enrollee currently has an approved walker (E0143) that was approved September 
23, 2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a folding, wheeled walker, adjustable or fixed height (E0143). The folding, 
wheeled walker, adjustable or fixed height (E0143) serves the same purpose as the walker. A cardiac walker is 
also not included on the walkers covered by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve an adult forearm walker (cardiac walker) (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Toric intraocular lens provided June 30, 2022 
 
You asked the Plan to reimburse you for intraocular lens. You say that on June 30, 2022, you had Toric lens 
implants for both eyes. As a result of your stroke, the permanent partial vision loss, remains without a remedy. 
The Plan denied your request. The Plan says nonconventional intraocular lenses, Toric lens, are not covered by 
Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to reimburse you for the Toric 
intraocular lens provided June 30, 2022
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 20, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 8, 2022, to 
February 6, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the HHA 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record does not support that an 
NOA with a one-time, artificial admission date for 2022 has been submitted to the Plan. Therefore, we decided 
that the Plan does not have to pay for home health services provided from January 8, 2022, to February 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs a ventilator to go home. The Plan 
denied your request. The Plan says the records do not show that the enrollee has failed bilevel positive airway 
pressure (BiPAP) or that the ventilator will be used in a setting that is not available on a BiPAP device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide bilevel or continuous 
positive airway pressure (BiPAP or CPAP) therapy, regardless of the underlying medical condition, shall not be 
covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare when used for this purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service February 22, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and were reported appropriately. The Plan denied your request. The Plan says this code is included in 
the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. 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) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that there was a frequency 
limit. The Plan denied your request. The Plan says your benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral imaging (D0210) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 26, 2022, to  
June 21, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a Licensed 
Professional Counselor is ineligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program.  Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
May 26, 2022, to June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on December 02, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on December 02, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on 
August 19, 2022. 
 
You asked the Plan to pay for the monitor. You say that the claim should be reprocessed for payment. The Plan 
denied your request. The Plan says there was no signed order from the prescribing provider for diabetic 
supplies in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that all durable medical equipment items require a 
written order/prescription from the treating practitioner for Medicare payment as a condition of payment.  
 
There is no evidence of any physician order for this item in the case file. Based on this information, we decided 
that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does 
not have to pay for a continuous glucose monitor provided to the enrollee on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) provided on March 3, 
2022. 
 You asked the Plan to pay for a medical eye examination (92014). You say that your PCP at the time would not 
issue a referral. The Plan denied your request. The Plan says per your plans benefit, before you receive services 
from an out-of-network ophthalmologist for diagnosis and/or treatment of a medical condition of the eye, you 
must first obtain a referral from your PCP. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from an in-network Plan vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that before you receive services from an out-of-
network ophthalmologist for diagnosis and/or treatment of a medical condition of the eye, you must first obtain 
a referral from your primary care physician (PCP). Based on this information, we decided that the Plan's rules 
for coverage of a medical eye examination (92014) have not been met. Therefore, we decided that the Plan 
does not have to pay for a medical eye examination (92014) provided on March 3, 2022.