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

 
We decided that the Plan does not have to waive the coinsurance for an in-network Hyaluronan or derivative, 
for intra-articular injection provided on May 22, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network Hyaluronan or derivative, for intra-articular 
injection. You say that you are in constant pain, the other injections did not work. You were not told about this 
other charge that you have been given. You cannot afford these, you are on a fixed income. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an in-network Hyaluronan or derivative, for intra-articular injection. This item/service falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $287.73 
($1,438.65 allowed x 20% = $287.73). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network Hyaluronan or derivative, for intra-articular injection provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility eye exam provided on July 20, 2023. 
 
You asked the Plan to pay for a facility eye exam. You say that the enrollee is in a facility and the facility 
should have obtained the prior authorization. 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 facility eye exam 
provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot x-ray provided on May 15, 2023. 
 
You asked the Plan to pay for the foot x-ray. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the foot x-ray provided 
on May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system and supplies. 
 
You asked the Plan to pre-approve Omnipod disposable insulin pump system and supplies. You say that the 
items are necessary. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that drugs and supplies used with disposable drug 
delivery systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Omnipod disposable insulin pump system and supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Omnipod disposable insulin pump system and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic shoe insert (A5500) provided on March 10, 2023. 
 
You asked the Plan to pay for the diabetic shoe insert. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for diabetic shoe insert (A5500) provided on March 
10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or receiver, and 
supply allowance. 
 
You asked the Plan to pre-approve the CMG and supply allowance. You say that you have diabetes and need to 
check your glucose levels 6 times a day and finger sticks have made your fingers numb. You also say that you 
can really use these sensors to help control your A1C, even if you are not at home. The Plan denied your 
request. The Plan says you are not treated with insulin for management of your diabetes. In addition, there is no 
documented history of problems with hypoglycemia. 
 
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 have diabetes, 
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 CMG and supply allowance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or 
receiver, and supply allowance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on June 
15, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that this is the plans fault as they 
made the appointment. You also say that you went to two dentists in June, and either one did not do anything 
but take x-rays and you are still in pain. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image has already been exhausted. 
 
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 panoramic radiographic image was exhausted on date of service June 13, 2023. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OIVIT services provided on May 25, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the documentation does not support the services 
billed. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an outpatient intravenous insulin therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the OIVIT services provided on May 25, 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 for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee can continue 
receiving their care in the current facility. 
 
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 LTACH transfer does not offer a therapeutic advantage to the enrollee. There are no 
services the enrollee needs that cannot be obtained in their current setting. Criteria is not met. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 23, 2023, billed with 
codes 81226, 81241, & 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 23, 2023, billed with codes 81226, 81241, & 81328.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J3370, J0882, A4657, 87340, 86706, 84460 
, 84450, 84295, 84155, 84132, 84100, 83540, 82728 , 82565 , 82435 , 82374, 82310, & 82040 provided on 
February 1, 2023 to February 27, 2023. 
 
You asked the Plan to pay for procedure codes J3370, J0882, A4657, 87340, 86706, 84460 , 84450, 84295, 
84155, 84132, 84100, 83540, 82728 , 82565 , 82435 , 82374, 82310, & 82040. You say that these services 
were medically necessary. The Plan denied your request. The Plan says these 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 J3370, J0882, A4657, 87340, 86706, 84460 , 84450, 84295, 84155, 84132, 84100, 
83540, 82728 , 82565 , 82435 , 82374, 82310, 82040 are not supported in the medical record. Specifically, 
payment for these services are consolidated in End Stage Renal Disease (ESRD) prospective Payment System 
(PPS) billing. The individual procedure codes are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes J3370, J0882, A4657, 87340, 86706, 84460 , 
84450, 84295, 84155, 84132, 84100, 83540, 82728 , 82565 , 82435 , 82374, 82310, & 82040 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes J3370, J0882, A4657, 
87340, 86706, 84460 , 84450, 84295, 84155, 84132, 84100, 83540, 82728 , 82565 , 82435 , 82374, 82310, & 
82040 provided on February 1, 2023 to February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown repair necessitated by restorative material failure 
(D2980) provided on May 16, 2023.  
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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 item or service was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown repair necessitated by restorative material 
failure (D2980) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need the denture because 
you had an extraction and your old denture needed to change. The Plan denied your request. The Plan says your 
benefit for the maxillary partial denture has already been exhausted. 
 
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 maxillary partial denture was exhausted on date of service November 27, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture  resin base 
(including, retentive/clasping materials, rests, and teeth) (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on May 01, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. 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 May 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(E2103, A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 have diabetes, 
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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies (E2103, 
A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power mobility device provided on February 28, 2023. 
 
You asked the Plan to pay for the power mobility device. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the power mobility 
device provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the smile saver membership plan provided on May 11, 2023. 
 
You asked the Plan to pay for the smile saver membership plan. You say that you do not understand why the 
claim keeps getting denied and you were expecting an 80% reimbursement for the dental services. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the smile saver 
membership plan 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, the smile saver membership plan is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the smile 
saver membership plan provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 9, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot (L4361) provided on April 25, 2023. 
 
You asked the Plan to pay for the boot. 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 for this type of orthosis, claim lines billed with 
codes without a KX, GA or GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The code was not billed with a required modifier. Based on this 
information, we decided that Medicare rules for coverage of the boot have not been met. Therefore, we decided 
that the Plan does not have to pay for a walking boot (L4361) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth originating site facility fee provided on  
May 5, 2023. 
 
You asked the Plan to pay for telehealth originating site facility fee. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for telehealth originating site facility fee provided on May 5, 2023.