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

 
We decided that the Plan does not have to pay for foot orthotics, shoe insert.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics, shoe insert.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. 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 31, 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 the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP device. You say that the requested CPAP machine (E0601) is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested CPAP machine (E0601).  
 
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 a CPAP device. Our reviewer says that 
the enrollee does not meet criteria for the requested CPAP machine (E0601).  Our physician reviewer found 
continued coverage of CPAP is not medically necessary.  This enrollee has obstructive sleep apnea and was 
prescribed CPAP on July 27, 2022.  The medical records do not include evidence of a follow-up visit or 
assessment of benefit and compliance in using the device. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology 
testing and take home supply of methadone; up to 7 additional day supply provided from February 5, 2023, to 
February 19, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group therapy, and toxicology testing and take 
home supply of methadone; up to 7 additional day supply. You say that you are a certified OTP. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program facility. 
 
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. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, 
individual and group therapy, and toxicology testing and take home supply of methadone; up to 7 additional 
day supply provided from February 5, 2023, to February 19, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Botox.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluticasone-Salmeterol. 
 
You asked the Plan to pre-approve Fluticasone-Salmeterol. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fluticasone-Salmeterol.  
 
Benefits for Fluticasone-Salmeterol may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says this drug is being dispensed by a pharmacy and is not being provided by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 31, 2023. 
 
You asked the Plan to pay for the emergency department visit. 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 services at issue were reimbursed 
by the Plan on February 21, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite crowns (D2710). 
 
You asked the Plan to pre-approve D2710. You say that you need this dental work. The Plan denied your 
request. The Plan says D2710 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
resin-based composite crowns (D2710).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the bifocal lenses provided on February 10, 
2023.  
You asked the Plan to pay for the frames and the bifocal lenses. You say that you had not used this benefit and 
it is already being denied for exceeding the benefit. The Plan denied your request. The Plan says the benefit has 
been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses a year. 
 
We looked at the file and the Plan's rules. Specifically, you received frames on February 10, 2023, with claim 
number 112378912900, which exhausted the benefit. Based on this information, we decided that the Plan's 
rules for coverage of the frames and the bifocal lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames and the bifocal lenses provided on February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for a total hip arthroplasty 
(27130) provided on December 2, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that assistant at surgery services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for assistant 
at surgery services have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for a 
total hip arthroplasty (27130) provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rhythm electrocardiogram (ECG), 1-3 leads; interpretation 
and report only rendered from November 14, 2022, to November 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a review of the documentation 
provided does not confirm that the rhythm ECGs in question were actually performed. There is insufficient 
documentation to support these procedures. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay for rhythm electrocardiogram (ECG), 1-3 leads; interpretation and report only rendered from 
November 14, 2022, to November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 for date of service September 23, 
2022. 
 
You asked the Plan to pay for procedure code 81479. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, no medical records were 
provided to support the codes billed. This means documentation to support the medical necessity of the test was 
not provided. Based on this information, we decided that Medicare rules for coverage of procedure code 81479 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 for date 
of service September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for colon hydrotherapy provided from 
October 21, 2022, to December 30, 2022. 
 
You asked the Plan to reimburse you for colon hydrotherapy. You say that colon hydrotherapy is medically 
necessary because your bowels are not working correctly since you had prostate surgery in October 2021. You 
say that without this service, you could not use the bathroom and you risk sepsis and death. The Plan denied 
your request. The Plan says the service received by the member was rendered by a provider that is not under 
contract with the health Plan and is not Medicare-certified. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The file shows that this spa is not Medicare-certified. Based on this 
information, we decided that Medicare rules for coverage of colon hydrotherapy have not been met. Therefore, 
we decided that the Plan does not have to reimburse you for colon hydrotherapy provided from  
October 21, 2022, to December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test (81479) provided April 28, 2022 
 
You asked the Plan to pay for the laboratory service. You say that the services you provided were medically 
necessary for the enrollee's condition and should be covered. The Plan denied your request. The Plan says the 
claim for this molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory service 
have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight psychotropic test 
(81479) provided April 28, 2022
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the injections, the medical supplies, the x-ray, the 
EKG, and the surgery provided on December 22, 2022. 
 
You asked the Plan to reduce the cost share for the injections, the medical supplies, the x-ray, the EKG, and the 
surgery. You say that you should only have a $300 copayment. The Plan denied your request. The Plan says 
that this cost sharing was charged correctly. 
 
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 has not provided the reprocessed Explanation of Benefits (EOB) or 
other documentation showing how the cost-sharing was applied. Therefore, we decided that the Plan has to 
waive the cost share for the injections, the medical supplies, the x-ray, the EKG, and the surgery provided on 
December 22, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283) provided on October 12, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the primary payer has already paid the allowed amount. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary payer has paid the allowable amount. As the secondary insurer, the Plan cannot be held 
responsible for the emergency room services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99283) provided on 
October 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 3, 2023, to 
January 10, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 324. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from January 3, 2023, to January 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician attendance and supervision of hyperbaric oxygen 
therapy provided on August 11, 2022.  
 
You asked the Plan to pay for physician attendance and supervision of hyperbaric oxygen therapy. The Plan 
denied your request. The Plan says the requested physician attendance and supervision of hyperbaric oxygen 
therapy does not meet the Medicare NCD coverage criteria.  
 
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 pay for physician attendance and supervision of 
hyperbaric oxygen therapy. Our reviewer says that the requested physician attendance and supervision of 
hyperbaric oxygen therapy is not considered medically necessary. Our physician reviewer found that the 
enrollee has a diagnosis of traumatic brain injury. The record sent by his provider indicates that he had a motor 
vehicle accident in 2008 and hyperbaric oxygen therapy in the past helped his cognitive abilities. The review 
has determined that the requested physician attendance and supervision of hyperbaric oxygen therapy does not 
meet the Medicare NCD 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 physician attendance and supervision of hyperbaric oxygen therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for physician attendance and supervision of 
hyperbaric oxygen therapy provided on August 11, 2022.