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

 
We decided that the Plan does not have to pay for procedure code K0553 billed for date of service December 
11, 2022. 
 You asked the Plan to pay for the billed services. You say that the documentation shows medical necessity. The 
Plan denied your request. The Plan says the service was not billed with an appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code K0553 was billed with primary diagnosis code E08.65. This diagnosis code has a code 
first note at the manifestation code. This code is not permitted to be used as the primary diagnosis code. 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 K0553 billed for date of service 
December 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care (99223) provided on December 
28, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 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hospice election has been revoked or terminated.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 enrollee ended Medicare Hospice benefits on December 27, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
care (99223) provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is not receiving insulin and they have not 
had any documented hypoglycemic episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
criteria coverage for a CGM was not met. Our physician reviewer found that the enrollee is not taking insulin 
nor having low blood glucose sugar levels that we are told of; the enrollee is not on a medication that typically 
causes low blood glucose sugar levels. The criteria provided indicate that the CGM is covered if the enrollee is 
having low blood glucose sugar levels or is taking insulin. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 
09, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you should not have to 
pay for routine lab work. 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 $15 
copayment for in-network outpatient diagnostic laboratory tests. 
 
You have been asked to pay a $15 copayment for the laboratory services. This item/service falls within the in-network outpatient diagnostic laboratory tests 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 record shows this claim was approved and you are responsible for the 
cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory 
services provided on March 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110), extractions (D7140), and 
alveoloplasty in conjunction with extractions (D7310) for tooth #26 and #27 provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that the previous denture did not fit properly, and 
you thought it would be covered when your new dental coverage began. The Plan denied your request. The 
Plan says your benefit for the complete upper denture and the extractions has already been exhausted. Also, the 
denial of payment for the alveoloplasty in conjunction with extractions is correct because it is 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, certain limitations apply. The record 
shows the Plan paid for a complete upper denture on April 14, 2021; therefore, your benefit for the complete 
upper denture was exhausted on the date of service of April 14, 2021. The record also shows that the Plan paid 
for 4 extractions on March 7, 2023; therefore, your benefit for the extractions was exhausted on the date of 
service of March 7, 2023. The alveoloplasty in conjunction with extractions is not covered under the Plans 
dental benefit. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110), 
extractions (D7140), and alveoloplasty in conjunction with extractions (D7310) for tooth #26 and #27 provided 
on March 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on October 07, 2022. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting the submitted documentation be 
reviewed. 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 ultrasound provided on 
October 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 27, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this 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). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need additional time. The Plan denied your 
request. The Plan says after receiving skilled services, your medical care can now be provided intermittently.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you no longer require the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. You do not require skilled nursing services, including complex 
wound management, tracheostomy care, bowel and bladder training and tube feeding, or administration of IV 
medications. Your wound care in and of itself does not necessitate skilled nursing facility admission and can be 
provided in the context of home health care or at a lower level of acuity. You are currently requiring contact 
guard assistance to supervision for activities of daily living and mobility. You may continue to benefit from 
therapy or assistance. However, this does not require the intensity of skilled therapy services provided in the 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not has a four-week trial of 
conservative therapy demonstrating failed response to treatment with an E0650 or E0651. 
 
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 that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, full arm (E0668) and a segmental pneumatic 
appliance for use with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the enrollee 
has tried 4 weeks of conservative therapy including compression and elevation without any relief. The Plan 
denied your request. The Plan says the records do not show that the enrollee has completed and failed a 4-week 
trial with a basic pump. It is also not clear if the increase in her swelling is due to the prolonged cellulitis and 
chest wall seroma described in the medical record, rather than strictly due to lymphedema. 
 
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 that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668) and a 
segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on December 30, 2022. 
 
You asked the Plan to pay for a nursing facility visit. 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 a nursing facility visit 
provided on December 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on December 28, 2022. 
 
You asked the Plan to pay for initial nursing facility care. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for initial nursing facility 
care provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from September 2, 2022, to September 22, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. The Plan denied your request. The 
Plan says this service does not meet the requirements of the Plan and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from September 2, 2022, 
to September 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on September 08, 2022. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting the submitted documentation be 
reviewed. 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 ultrasound provided on 
September 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed the entire $160 per 
your plan. The Plan denied your request. The Plan says your benefit for the requested services $750 dollar limit 
was met. The Plan has already paid the maximum allowance for nonMedicare covered dental services in 2023 
and no further payments are due to you. 
 
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 services was exhausted on date of service February 9, 2023, and February 
20, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established 
patient (D0120), and prophylaxis - adult (D1110) provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on January 26, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that this 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). Therefore, we decided that the Plan does not have to pay for an office visit, and 
related services provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 15, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trivisc injection. 
 
You asked the Plan to pre-approve a Trivisc injection. You say that a Trivisc injection is medically necessary. 
The Plan denied your request. The Plan says the requested Trivisc injection is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 a Trivisc injection. Our reviewer says 
that a Trivisc injection is not considered medically necessary in this case. Our physician reviewer found that 
the previous injection that was provided over 12 months prior was noted to have decreased your pain levels. However, your functional capacity was not clearly documented to have increased with the previous series of 
injections. You are noted to have had three prior series of gel injections. Additionally, detailed documentation 
is not evident regarding continuing conservative measures that fail to improve the noted pain and decreased 
function. Therefore, the requested Trivisc injection does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Trivisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Trivisc injection.
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 are requesting IRF services so you can return 
safely to your prior level of function and/or maximum potential. 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.