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) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that you need the requested CGM 
for your condition. The Plan denied your request. The Plan says you do not meet coverage criteria for the 
requested 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 you do 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 Libre 2 CGM 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM) sensor (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tramadol. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve tramadol.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) and precision attachments 
(D5862) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be paid under your 
medical coverage. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because prosthodontics that replace teeth that were extracted before the enrollee's effective date are not 
covered by the Plan and the precision attachments are not covered by the Plan. 
 
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 precision attachments are not 
among those covered under this benefit. Also, the record shows the complete denture is replacing 1 or more 
teeth that were missing prior to the enrollee eligibility under the Plans dental benefit contract. Therefore, we 
decided that the Plan does not have to pay for a complete lower denture (D5120) and precision attachments 
(D5862) provided on August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid examination for both ears (92591), a binaural 
dispensing fee (V5160), hearing aid supply/accessories (V5267), and a digital hearing aid (V5261) provided 
from June 13, 2022, to July 25, 2022. 
 
You asked the Plan to pay for a hearing aid examination for both ears (92591), a binaural dispensing fee 
(V5160), hearing aid supply/accessories (V5267), and a digital hearing aid (V5261). You say that your 
audiologist checked to see if the Plan covered hearing aids and was told they did. You also say you found you 
have to go elsewhere for the hearing aids. The Plan denied your request. The Plan says the services were 
received at a provider other than the Plan hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided from an in-network, Plan specific provider and Plan specific brand.  
 
 
  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 a hearing aid examination for both ears 
(92591), a binaural dispensing fee (V5160), hearing aid supply/accessories (V5267), and a digital hearing aid 
(V5261). Our reviewer says that  Our physician reviewer found  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a hearing aid examination for both ears (92591), a binaural dispensing fee 
(V5160), hearing aid supply/accessories (V5267), and a digital hearing aid (V5261) have not been met. 
Therefore, we decided that the Plan does not have to pay for a hearing aid examination for both ears (92591), a 
binaural dispensing fee (V5160), hearing aid supply/accessories (V5267), and a digital hearing aid (V5261) 
provided from June 13, 2022, to July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee will have excessive sputum 
if secretions are not cleared properly. The Plan denied your request. The Plan says the enrollee does not have a 
covered condition. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed 
diagnosis of bronchiectasis do not meet this criterion.  This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary after surgery. The Plan denied your request. The Plan says the procedure is currently 
approved as an ambulatory procedure. There is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
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 acute inpatient hospital care is met in 
this case. Our physician reviewer found the enrollee is undergoing a planned left total knee 
arthroplasty. The enrollee was medically stable and has been provided medical clearance to undergo this 
elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has 
determined that the record does not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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 acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code(s) 88305. You say that you would like the Plan to reconsider 
their denial of payment. 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service January 10, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that these services 
were medically necessary and should be paid as billed. 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, 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) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service January 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 29, 2022 to 
February 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 29, 2022 to 
February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627), an unlisted special service 
(99199) and sales tax (S9999) provided on July 12, 2022. 
 
You asked the Plan to pay for a seat lift mechanism, an unlisted special service and sales tax. You say that you 
disagree with the denial and are requesting reconsideration. You have included the receipt. The Plan denied 
your request. The Plan says the item obtained by you was rendered by a provider who is not under contract 
with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627), an 
unlisted special service (99199) and sales tax (S9999) provided on July 12, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound of the abdominal aorta (76706) provided on June 23, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that 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 Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have been met. Specifically, the service was billed with CPT code 76706 as directed 
by Medicare guidelines. This service was billed with a screening diagnosis, and there are no Medicare criteria 
regulating what diagnosis codes must be billed for this service. Therefore, we decided that the Plan has to pay 
for the ultrasound of the abdominal aorta (76706) provided on June 23, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy (97113), physical therapy evaluation 
(97162), and physical performance test (97750). 
 
You asked the Plan to pre-approve aquatic therapy (97113), physical therapy evaluation (97162), and physical 
performance test (97750). You say that you suffer from upper back, arm, and neck pain. The member also says 
she is experiencing numbness. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for aquatic therapy. 
 
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 aquatic therapy (97113), physical 
therapy evaluation (97162), and physical performance test (97750). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found despite the number of treatment sessions; you still continue to experience the same symptoms. Our 
physician reviewer also found that other treatment modalities may be considered aside from aqua therapy. Our 
physician reviewer also found that aqua therapy has not proven beneficial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy (97113), physical therapy evaluation (97162), and physical 
performance test (97750) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
aquatic therapy (97113), physical therapy evaluation (97162), and physical performance test (97750).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 22, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the member 
was under hospice on this date of service. Therefore, the claim is the responsibility of traditional Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic foot inserts (A5514). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
items. 
 
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. Additionally, the rules state that inserts used in non-
covered shoes are noncovered. The Plan follows these same rules.   
 
Records show that the enrollee does not meet criteria for coverage of the requested items. Specifically, the 
documentation provided by your organization does not indicate that the enrollee has appropriate shoes for the 
requested inserts. This information was requested by the Plan but was not received. Medicare rules say that 
inserts used in non-covered shoes are non-covered. Therefore, we decided that the Plan does not have to pre-
approve diabetic foot inserts (A5514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with a urologist to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that the requested provider is an expert in the field of 
urology. You have a rare medical condition and you have seen other doctors, but the opinion is unclear as to 
how you should proceed with treatment. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. There are in-network providers available. 
 
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 
office visits with a urologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
for tooth 14. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation (D7953) for tooth 14. You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says this service code is 
not listed and is not a covered benefit. 
 
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 pre-approve bone 
replacement graft for ridge preservation (D7953) for tooth 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apicoectomy (D3426). 
 
You asked the Plan to pre-approve apicoectomy (D3426). You say that this is a medically necessary surgery. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 pre-approve 
apicoectomy (D3426).