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

 
We decided that the Plan does not have to pay for wound care services provided on February 08, 2023. 
 
You asked the Plan to pay for wound care services. You say that the services were medically necessary. 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 wound care services 
provided on February 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on November 15, 2022. 
 
You asked the Plan to pay for an outpatient surgery. You say that the services were medically necessary. 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 outpatient surgery 
provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit, and related services provided on October 
17, 2022. 
 
You asked the Plan to pay for an outpatient 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 outpatient visit, and 
related services provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift. 
 
You asked the Plan to pre-approve the lift. You say that the notes state that you are unsteady on your feet, and 
have limits in motion. The Plan denied your request. The Plan says the information available does not that you 
require positioning for transfers. 
 
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 lift. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the records do not support that you are dependent upon a lift to transfer from the bed. You must use 
a wheelchair for mobility, but your transfer status is not addressed. 
 
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 lift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a patient lift.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the ear mold/insert (V5264) provided on May 26, 2022. 
 
You asked the Plan to pay for the ear mold/insert. You say that you were advised by the Plan that the provider 
you went to was in-network. The Plan denied your request. The Plan says that you did not use a Plan-approved 
provider. 
 
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. The records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the ear mold/insert. Specifically, you stated that 
the Plan advised that the provider you saw was in-network, and that the provider's office also contacted the 
Plan and was advised the same. There is no documentation provided showing the Plan did not advise that the 
treating provider was OON. It is the burden of the Plan to substantiate their denial with evidence. In this case, 
the denial has not been substantiated. Therefore, we decided that the Plan has to pay for the ear mold/insert 
(V5264) provided on May 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), bifocal lenses (V2200), and progressive 
lenses (V2781) provided on November 29, 2022 from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames, bifocal lenses, and progressive lenses. You say that you would like to 
be reimbursed the $136.00 for your glasses. The Plan denied your request. The Plan says this reimbursement 
request is not eligible for reimbursement. The Plan also says there is not an exception that would allow the Plan 
to cover eyewear purchased from an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use the Plan's in-network vendors to obtain eyewear 
benefits. 
 
 We looked at the file and the Plan's rules. The record shows that you received this eyewear from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the frames, bifocal lenses, 
and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames (V2020), bifocal lenses (V2200), and progressive lenses (V2781) provided on November 29, 2022 from 
an out-of-network (OON) provider.
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 a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval 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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (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 pay for the Cxbladder Monitor test (0013M) provided on December 
5, 2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test . You say that this service was medically necessary 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on December 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 20, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 12, 
2022.  
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for lower leg weakness and was transferred to skilled 
nursing on May 11, 2023. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 and 99140 billed for date of service 
December 16, 2022. 
 
You asked the Plan to pay for procedure code 99100 and 99140. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure code 99100 and 99140 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 and 99140 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99100 and 99140 is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99100 and 99140 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99100 and 99140 billed for date of service December 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) Tooth #2 provided 
on November 23, 2022. 
 
You asked the Plan to pay more for dental services. You say that the service should be covered. The Plan 
denied your request. The Plan says the benefit was paid at the least costly method of treatment, and the enrollee 
is responsible for the remaining balance. 
 
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. This benefit includes crown - 
porcelain/ceramic covered once within 84 months per tooth when teeth cannot be restored with regular filings 
due to fracture or decay. You pay 50% coinsurance after $100 deductible for class 3 major services. 
  Though the Plan offers a dental benefit in excess of Medicare coverage that covers the requested crown - 
porcelain/ceramic (D2740), the Plan processes it as crown - porcelain fused to predominantly base metal and 
you are responsible up to the contracted fee. You are responsible for the difference between the allowed 
amounts, which is $89 ($771- $1,453 = $682). You also have a $100 deductible and a 50% coinsurance of $   
($771/allowed amt - $100 deductible = $671 x 50% = $335.50). The total you pay $100 + $682 + $335.50 = 
$1,117.50. Therefore, we decided that the Plan does not have to pay more for crown - porcelain/ceramic 
(D2740) Tooth #2 provided on November 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need additional rehabilitation after having been 
hospitalized. The Plan denied your request. The Plan says your condition does not meet Medicare guidelines 
for services in 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic CGM and supplies. 
 
You asked the Plan to pay for a therapeutic CGM and supplies. You say that you disagree with the denial for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
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 pay for  a therapeutic CGM and supplies. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
diabetes mellitus and is insulin treated only once daily. Also, the provided records in this case do not document 
the beneficiarys insulin treatment regimen requires frequent adjustment. Therefore, the enrollee does not meet 
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 therapeutic CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for a therapeutic CGM and supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital observation stay 
provided from January 29, 2023, to January 30, 2023. 
 
You asked the Plan to waive the copayment for an outpatient hospital observation stay. You say that you do not 
agree with the charge for occupational therapy because the therapist determined you did not require therapy 
services. 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 $350 
copayment for outpatient observation stay.  
 
 
  You have been asked to pay a $156.54 copayment, which is less than the standard copayment for an outpatient 
hospital observation stay. This item/service falls within the outpatient hospital observation 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 outpatient hospital observation stay provided from 
January 29, 2023, to January 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 25, 2022, billed with 
codes 71275-26 and 74174-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 14, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the imaging services provided have not been met.  
Therefore, we decided that the Plan does not have to pay for imaging services provided on June 25, 2022, 
billed with codes 71275-26 and 74174-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99233) provided on October 3, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient with at least 2 of the 3 key components: a detailed interval history, a 
detailed examination, medical decision making of high complexity. 
 
We asked our coder 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 the inpatient care. Our reviewer says that the provided 
records do not support the code billed. Our reviewer found the documentation did not include records of a detailed history or physical exam. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient care (99233) provided on October 3, 2022.