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

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 Sensor. The Plan denied your request. The Plan says 
the FreeStyle Libre 3 Sensor is not eligible for Medicare Coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 4, 2023, to January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on January 4, 2023, to January 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the primary care provider office visit provided on 
October 10, 2022. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that you only 
had your blood pressure taken and were not seen by the provider. The Plan denied your request. The Plan says 
that the cost share was applied 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 did not provide the correct Evidence of Coverage (EOC). Without a 
valid EOC we are not able to determine if the cost sharing was applied correctly. Therefore, we decided that the 
Plan has to waive the copayment for the primary care provider office visit provided on October 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 13, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76641-RT is Ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical record does not reflect that a 
complete ultrasound of the breast including all 4 quadrants and the retroareolar region was examined. The record demonstrates a limited breast ultrasound. There is a more specific code for this service. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydroxychloroquine. 
 
You asked the Plan to pre-approve hydroxychloroquine. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says self-administered drugs are covered under the pharmacy 
benefit. 
 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 hydroxychloroquine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH level of care 
to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met in the current hospital 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that you need additional 
transportation for dialysis. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for the portable gaseous oxygen 
system (E0431) and oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the enrollee currently has oxygen from 
your company that is due for re-authorization. The Plan denied your request. The Plan says the enrollee meets 
the medical necessity for oxygen, however rental payments have been met per LCD and DME company is 
responsible for continued care, service and maintenance from moth 37-60. 
 
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 case file did not include a claims history that supports 36 months of 
payments had been paid for the oxygen equipment. The claims history was not included in the case file. 
Therefore, we decided that the Plan does not have to pre-approve continued coverage for the portable gaseous 
oxygen system (E0431) and oxygen concentrator (E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCISionRT provided on December 14, 2022. 
 
You asked the Plan to pay for the DCISionRT. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is not listed in the DEX database as a covered test. Based on this information, we decided that Medicare rules for coverage of the DCISionRT have not been met. Therefore, 
we decided that the Plan does not have to pay for the DCISionRT provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that the enrollee is at a greater risk of falling 
without a walk-in shower. The Plan denied your request. The Plan says this item is not covered by Medicare 
because it is not primary medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transplant care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve transplant care to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
transplant care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says the services are not urgent/emergent in nature and are available in-Plan. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve physician's services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for physician's services to be provided by an out-
of-network provider. 
 
You asked the Plan to provide coverage for the physician's services to be provided by an out-of-network 
provider. You say that the services are medically necessary. The Plan denied your request. The Plan says when 
you enrolled in a Medicare Advantage Plan, you selected a Primary Care Physician to coordinate/authorize 
your medical care. 
 
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 provide coverage from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to provide coverage for these services. Therefore, we decided that the Plan does not have to provide 
coverage for physician's services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that Eylea is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Eylea have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that treatment 
with Eylea is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drug bevacizumab before they will approve the requested drug. The enrollee has not tried and 
failed the required drug. The documentation does not support that bevacizumab would likely be less effective 
and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Eylea (J0178).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (71045) provided on August 25, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that your dispute was not received within 60 days of 
the claim determination. 
 
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. Specifically, the Plan has indicated that this appeal has been denied based on the 
60-day filing time frame. This is not an appropriate denial. Additionally, the Plan has not forwarded a claim or 
denial of the claim to show when or why the services at issue were denied. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated, so we must 
find in your favor. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided on 
August 25, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of intrauterine device (58300), and Levonorgestrel-
releasing intrauterine contraceptive system (J7301) received on November 9, 2022. 
 
You asked the Plan to pay for insertion of intrauterine device, and Levonorgestrel-releasing intrauterine 
contraceptive system. You say that you thought this would be covered. The Plan denied your request. The Plan 
says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
   
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
insertion of intrauterine device (58300), and Levonorgestrel-releasing intrauterine contraceptive system (J7301) 
received on November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 29, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95816 is electroencephalogram (EEG); including 
recording awake and drowsy. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found the code in question is not supported by the 
medical record due to missing key components of the code description.  
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on February 6, 2023. 
 
You asked the Plan to pay for the x-rays. You say that the provider did not ask if you wanted the x-rays. You 
say the provider just performed the services, and you feel you should not be responsible for this. 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 August 1, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on February 6, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is needed because the 
enrollee has Type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the 
required criteria has not been met, the request for the continuous glucose monitor cannot be approved as 
reasonable and necessary. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM and supplies. Our reviewer 
says that the enrollee does not meet coverage. Our physician reviewer found the enrollee must be adjusting 
insulin doses in the multiple daily injections regimen frequently to qualify for the CGM. The enrollee is not 
doing this based on the data provided. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) and supplies.