Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility services provided from June 1, 2022, 
to August 1, 2022. 
 
You asked the Plan to pay for assisted living facility services. You say that the rehabilitation was medically 
necessary for the member to remain in the skilled nursing facility. The Plan denied your request. The Plan says 
the services at issue in this case are considered custodial in nature and not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of assisted living facility services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for 
assisted living facility services provided from June 1, 2022, to August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor Kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor Kit. You say that the CGM will provide better 
blood sugar management. The Plan denied your request. The Plan says the enrollee does not require insulin 
three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 Sensor Kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor Kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device. 
 
You asked the Plan to pre-approve the oral device. You say that the mouth guard is for TMJ which is tempo 
mandibular joint dysfunction. This is a mouth guard, an oral appliance that you use to keep you from grinding 
your teeth in your sleep. The Plan denied your request. The Plan says a dental guard is not a covered benefit 
under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Oral occlusal appliances used to treat temporomandibular joint (TMJ) 
disorders are excluded. Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic 
device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Opioid Treatment Program (OTP) services provided on December 26, 
2022. 
 
You asked the Plan to pay for the OTP services. You say that your facility is enrolled as a Medicare OTP 
provider, so this claim should be paid. The Plan denied your request. The Plan says that these services must be 
billed by the facility directly on the facility's claim, not on a professional claim. 
 
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 Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTP services have been met  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTP services have been met. Therefore, we decided that the Plan has to pay for Opioid 
Treatment Program (OTP) services provided on December 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services billed with codes 74240, 74230, 72040, 
70100, and 70310 for date of service November 18, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
there were no contracted providers who could have provided these services. The Plan denied your request. The 
Plan says codes 74240, 74230 are not covered.  The Plan also says that the remaining codes were billed with an 
incorrect Place of Service code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must bill services with the correct POS 
code.  Medicare rules also say that only certain services can be provided as portable x-ray services. Procedures 
which require the use of contrast material or administration or injection of a substance are excluded from 
coverage as portable x-ray services. 
 
In regards to codes 72040, 70100, and 70310, you billed these services with POS code 11, which indicates that 
the services were provided in an office setting.  They were not. The records clearly show that your organization 
is a portable x-ray company that visited the patient's nursing facility to provide these services.  You should 
have billed the POS code that corresponds to the physical location of the facility where the services were 
rendered. That is why the Plan does not have to pay for codes 72040, 70100, and 70310. 
 
Regarding codes 74240 and 74230, these are radiology studies that require the administration of barium.  The 
rules explicitly exclude barium studies from coverage by a portable x-ray provider.  Therefore, the Plan doesn't 
have to pay for these codes either.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services billed with codes 74240, 74230, 72040, 70100, and 70310 for date of service November 
18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) Freestyle Libre. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM) Freestyle Libre. You say that your 
previous insurance was authorized without having to have a prior authorization and you had a copayment. You 
also say that the FreeStyle Libre provides up-to-date data on your blood sugars and helps you review your diet 
daily. The Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor (CGM) Freestyle Libre have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) Freestyle Libre.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
21, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for ambulance services. This item/service falls 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 ambulance services 
provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services billed with code 88305 for December 
27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 January 11, 2023. 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services billed with code 88305 for December 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on January 
03, 2023. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you thought that this service 
was covered. 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 $20 
copayment for in-network Medicare-covered chiropractic services. 
 
You have been asked to pay a $20 copayment for chiropractic services. This item/service falls within the in-
network Medicare-covered chiropractic 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 chiropractic services provided on January 03, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the services are necessary. The Plan denied your 
request. The Plan says routine costs associated with a clinical trial are not payable by the enrollee's plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Udenyca as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Udenyca.
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 
January 4, 2023. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that the enrollee left 
the ER before being treated. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care.  
 
 
  The enrollee has been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an emergency room (ER) visit provided on January 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on December 27, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the supplies supplies 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 wound care supplies 
provided on December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on December 15, 2022. 
 
You asked the Plan to pay for a drug test. You say that the services 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 drug test provided on 
December 15, 2022.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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 outpatient services (G0402, G0463) provided on November 
3, 2022. 
 
You asked the Plan to pay for the outpatient 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 codes G0402, & G0463 are not supported in the medical record. Specifically, two evaluation 
and management services were reported on the same date of service without the required G0 condition code. 
Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient services (G0402, G0463) provided 
on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 17, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services billed with code 00300 on date of service 
July 19, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you should not be receiving a bill for this 
service and you have called them numerous times. The Plan denied your request. The Plan says the provider 
did not bill these anesthesia services with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia services must be billed with one of the 
following modifiers to indicate the rate at which the service should be paid: AA, AD, G8, G9, QK, QS, QV, or 
GC. The anesthesia provider in this case did not bill with one of these modifiers, which is why the Plan cannot 
be obligated to pay for this service.  You may contact the provider directly to ask them to rebill this service 
with the correct required modifier. 
 
We looked at the file and Medicare rules. 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 billed with code 00300 on date of service July 19, 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. The Plan denied your request. The Plan says the information we 
have about the enrollee's condition does not meet all the requirements, services may be provided safely at 
alternate settings if requested, at a skilled nursing facility, outpatient setting or home health care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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.