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

 
We decided that the Plan does not have to pre-approve a heavy-duty walker. You asked the Plan to pre-approve the requested item. You say that the larger walker is sturdier. The Plan 
denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The file does not show that you meet the weight requirements for the 
requested walker. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 CGM device (E2103). 
 
You asked the Plan to pre-approve a Dexcom G7 CGM. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies have not 
been met.. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Dexcom G7 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 CGM device (E2103).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you cannot walk and need a 
wheelchair for your appointments. The Plan denied your request. The Plan says coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested wheelchair is for use outside of the home. Although this item may be helpful, neither Medicare 
nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to 
pre-approve a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies, and needle electromyography 
services provided on September 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nerve conduction studies and needle electromyography services. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
 
 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 nerve conduction studies, and needle 
electromyography services provided on September 12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on May 29, 2023. 
 
You asked the Plan to pay for the COVID-19 testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the enrollee was not symptomatic, hospitalized, or employed in health care. This 
means the COVID-19 testing at issue was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 testing provided on May 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records proving 
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 an office visit provided 
on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
September 18, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that this service is 
supported in the records. 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). Although the Plan has a Point-of-Service (POS) option to cover certain out-of-
network services, this benefit only applies to covered routine dental services. Therefore, we decided that the 
Plan does not have to pay for a home or residence visit for the evaluation provided on September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on January 
26, 2023, to March 30, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgeries. You say that you disagree with 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 $275 
copayment for outpatient surgery/Medicare-coveredsurgery. 
 
You have been asked to pay a $275 copayment for outpatient surgeries. This item/service falls within the 
outpatient surgery/Medicare-coveredsurgery 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. The total amount you owe is $550 ($275 x 2 visits = $550). Therefore, we 
decided that the Plan does not have to waive the copayment for outpatient surgeries provided on January 26, 
2023, to March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 3, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says these services were not authorized. 
 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 did not pre-approve the 
items/services 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 August 3, 
2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service August 18, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 76770 
is a column II code to column I code 93976. 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 76770 billed for date of service August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service December 
22, 2022, to January 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was treated for post-surgical 
lymphedema. The Plan denied your request. The Plan says the device is not eligible for reimbursement. 
 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 E0675 was billed for the treatment of lymphedema. A PCD coded as E0675 is used in 
the treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code E0675 billed for dates of 
service December 22, 2022, to January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service February 14, 
2023.  
 
You asked the Plan to pay for procedure code 12002. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 12002 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 12002 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 12002 billed for date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 2, 2021, to August 21, 
2021, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this provider is out-
of-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 2, 2021, to August 21, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
15, 2023.  
 You asked the Plan to pay for procedure code 86077. You say that medical records were provided. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88341 billed for date of service 
August 12, 2023.  
 
You asked the Plan to pay for procedure codes 88360 and 88341. The Plan denied your request. The Plan says 
the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6, and MUE for CPT code 88341 is 13. The MAI value for these 
codes is 3. You billed 18 units of code 88360 and 34 units of code 88341, exceeding the MUE. You did not 
provide all the required evidence showing that the excess units were actually provided, were correctly coded, 
and were medically necessary. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88360 and 88341 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88360 and 88341 billed for date of service August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
reasonable and necessary to solve the enrollee's chronic low back pain. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is not clear. There is no magnetic resonance imaging (MRI) 
showing only Modic changes without facet degenerative joint disease or stenosis. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on August 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 21, 
2023, to July 19, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $395 
copayment for inpatient hospital care. 
 
You have been asked to pay a $395 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $790 ($395 x 2 admission = $790). Therefore, we decided 
that the Plan does not have to waive the copayment for inpatient hospital care provided on June 21, 2023, to 
July 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need these services to continue with your 
recovery. The Plan denied your request. The Plan says Original Medicare is responsible for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The record shows your Medicare hospice benefits ended on December 1, 2023. Original Medicare will be 
responsible for services until the first day of the month after your benefit ended. Therefore, we decided that the 
Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on August 27, 2023. 
 
You asked the Plan to pay for the remote monitoring services. You say that you are requesting reconsideration 
of the denied claim. 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 remote monitoring 
services provided on August 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 17, 2022, to March 
18, 2022. 
 You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 18, 2022. The NOA was not received by the Plan until December 
7, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from February 17, 2022, to March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel (code 80050) provided on May 2, 
2023. 
 
You asked the Plan to pay for 80050. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 80050 is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 80050 have not been met. Therefore, we decided that the Plan does not have to pay for a general 
health panel (code 80050) provided on May 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that this service was supposed to be a 
free consultation. 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 $40 
copayment for in-network outpatient mental health care. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the in-network 
outpatient mental health care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office 
visit provided on July 27, 2023.