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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee's condition is uncontrolled. You say that 
the enrollee needs this CGM to learn to control it better. You also say that it will reduce future complications. 
The Plan denied your request. The Plan says the criteria have not been met. 
 
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 a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you are obligated by law to test specimens 
when ordered. Please reconsider. 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 laboratory services 
provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99221. You say that the billed services were medically 
necessary. The Plan denied your request. The Plan says payment for code 99221 is bundled into payment for 
code 99223. 
 
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 99221 is a column II code to column I code 99223 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 99221 
billed for date of service July 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopic procedures (57425, 58542) on October 20, 
2022. 
 
You asked the Plan to pay for laparoscopic procedures. You say that the out-of-network provider was the only 
available assistant at the time of the procedure. The Plan denied your request. The Plan says this provider is 
nonparticipating and based on specialty and taxonomy is not eligible for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for laparoscopic procedures (57425, 58542) 
on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that your neck and shoulder are causing you pain 
due to having night terror. The Plan denied your request. The Plan says massage therapy outside of a physical 
therapy setting is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should qualify for this benefit. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on December 20, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that you were not advised that the provider 
was out-of-network. 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 new patient office visit 
provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were not aware that you would see the NP 
instead of the doctor. 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 office visit provided 
on January 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on November 17, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you want to appeal the amount 
being charged. 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including X-rays. Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $248.82 and the allowed amount is $76.08. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $76.08. 
 You have been asked to pay a $76.08 copayment, which is less than the copyment for an ultrasound. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound on November 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an aspirin chewable tablet provided on January 2, 2023. 
 
You asked the Plan to pay for the self-administered drug. You say that you are not happy the hospital charged 
$4 for a drug that costs a fraction of the cost. 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 pay for an aspirin chewable tablet 
provided on January 2, 2023.  
 
Benefits for the self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pin retention (D2951). 
 
You asked the Plan to pre-approve pin retention. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 pin 
retention (D2951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses received on November 25, 2022. 
 
You asked the Plan to pay for eyeglasses. You say that you were unaware that the provider was not contracted 
with Medicare. The Plan denied your request. The Plan says this provider is on the preclusion list and not 
eligible with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for eyeglasses received on November 25, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you never 
called or  took a transport and you were driven to the urgent care facility by your sister. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 7, 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. 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: 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 illness that requires aggressive wound care. The Plan denied your request. The 
Plan says the enrollee's medical needs are being met in the current setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
July 18, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that this was medically 
necessary. The Plan denied your request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are 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 office visit provided 
on January 10, 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 to receive the proper level of care and services. The Plan denied your request. The Plan says the 
enrollee is receiving the appropriate level of inpatient acute care and is currently unstable for transfer to an 
LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 physician services provided on December 28, 2022. 
 
You asked the Plan to pay for the specialist office visit. You say that these services were medically necessary. 
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. The 
enrollees contract with the Plan says that there is a $1,000 deductible which applies to physician/practitioner 
services, including doctor's office visits. The enrollees contract with the Plan also says there is 40% 
coinsurance once the deductible has been met for out-of-network provider and professional services. The items or services you asked the Plan to pay for fall within the physician/practitioner services, including 
doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,000 deductible which applies to out-of-network physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the physician services were received on December 28, 2022. Therefore, we decided that the Plan does not have 
to pay for physician services provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 13, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the occupational therapy (OT) services received on October 27, 2022. 
 
You asked the Plan to pay for OT services. You say that it was a mandatory test according to your doctor, 
because of your dementia symptoms. The Plan denied your request. The Plan says that the documentation 
submitted provides no additional information that justifies this request. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 OT evaluation. Our reviewer says that the 
OT evaluation was medically necessary. Our physician reviewer found the evaluation was necessary given your 
medical history of impaired cognition. The evaluation was necessary to determine your ability to safely operate 
a motor vehicle. This evaluation can only be performed by a skilled occupational therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OT evaluation have been met. Therefore, we decided that the Plan has to pay 
for the occupational therapy (OT) services received on October 27, 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.