Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99490 provided on February 27, 2023. 
 
You asked the Plan to pay for procedure code 99490. 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. 
 
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, the file shows that medical records were provided to the Plan; 
however, the Plan only included medical records for the incorrect patient from a different provider. The file 
does not show that the Plan made any attempts to obtain the correct medical records which are needed in this 
case to determine if the Plan's reasoning for the denial of payment meets Medicare criteria. Therefore, we 
decided that the Plan has to pay for procedure code 99490 provided on February 27, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on June 27, 2023, through 
June 29, 2023. 
 
You asked the Plan to pay for the medication. You say that this should be covered. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 pay for self-administered drugs provided 
on June 27, 2023, through June 29, 2023.  
 
Benefits for the medication 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 reimburse for bifocal lenses (V2200), photochromatic tint (V2744), 
anti-reflective coating (V2750) and frames (V2020) provided on July 21, 2023. 
 
You asked the Plan to reimburse for bifocal lenses (V2200), photochromatic tint (V2744), anti-reflective 
coating (V2750) and frames (V2020). You say that paying this money presents a hardship for you as your 
income is limited and your expenses are high. The Plan denied your request. The Plan says this benefit has 
been exhausted. 
 
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 a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $200 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses. The Plan rules also say you are responsible for any amount over the 
$200 retail price. The record shows the benefit was exhausted with this date of service. Based on this 
information, we decided that the Plan's rules for coverage of bifocal lenses (V2200), photochromatic tint 
(V2744), anti-reflective coating (V2750) and frames (V2020) have not been met. Therefore, we decided that 
the Plan does not have to reimburse for bifocal lenses (V2200), photochromatic tint (V2744), anti-reflective 
coating (V2750) and frames (V2020) provided on July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on July 12, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says over the counter (OTC) COVID-19 tests are 
not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on July 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 28, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the copayment applied for an ER visit. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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. You have been asked to pay $70.31, which is less than the standard copayment for an ER visit. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on May 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab (J9299). 
 
You asked the Plan to pre-approve nivolumab. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the requested use of this drug is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 nivolumab. Our reviewer says that the 
requested use of nivolumab is not supported. Our physician reviewer found the Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's specific condition. The requested use of 
nivolumab is also not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nivolumab (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment purchased on February 23, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you were told that your insurance would 
reimburse you for the cost of purchased oxygen equipment. The Plan denied your request. The Plan says the 
purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
equipment purchased on February 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on July 4, 2023.  
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the transport of a Medicare 
beneficiary must occur for an ambulance transport to be payable under the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on July 4, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on July 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
14, 2023, and July 22, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you think that the 
copayment is too high. 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 $200 
copayment per one-way trip ambulance services. 
 
 
 You have been asked to pay a $400 copayment for the ambulance services ($200 copayment x 2 services = 
$400). These items/services fall within the ambulance services 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 the ambulance services provided on July 14, 2023, and July 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the continuous glucose monitor have been met. No medical records were submitted to support the request. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve the Freestyle Libre sensor kit. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee is not 
on insulin and does not meet the Medicare criteria. 
 
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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia, had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day continuous 
glucose monitor (CGM) system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on May 
15, 2023. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90837 is not supported in the medical record. Specifically, the claim was billed with 
place of service 11 (office) however, records show that this service was a telehealth service. The claim was not 
billed with the correct place of service (02, telehealth). Based on this information, we decided that Medicare 
rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient mental health services (90837) provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a dental 
consultation (D9310) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-rays, and periodontal 
maintenance (D7140, D0220, D5820) provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation, 
intraoral x-rays, and periodontal maintenance (D7140, D0220, D5820) provided on December 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional trips for routine transportation. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are necessary 
for you to get to your dialysis appointments. The Plan denied your request. The Plan says you have used up 
your transportation benefit for the calendar year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 20 additional trips for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0671). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show lymphedema extending onto 
the chest, trunk and/or abdomen after a four week trial. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0652, E0671).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81433) provided on May 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS payment policy does not allow separate 
payment for multiple methods to test for the same analyte. 
 
We looked at the file and Medicare rules. Procedure code 81433 represents a service that is included in code 
81432. This code was already approved. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (81433) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, intraoral x-rays, bitewing x-
rays, and cleaning (D0120, D0220, D0274, D1110) provided on July 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation, intraoral x-rays, 
bitewing x-rays, and cleaning (D0120, D0220, D0274, D1110) provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 7, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81456 is bundled into 
payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 81456 billed for date of service March 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary due 
to the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's records do 
not show that it is medically safe for them to leave the hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable for transfer and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
Completion of treatment at the current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (64447, 64450) provided on May 16, 
2023. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed codes are not separately payable. 
 
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 codes 64447, & 64450 are not supported in the medical record. Specifically, these services 
are included in the base anesthesia code also billed (01402). Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (64447, 64450) provided on May 16, 2023.