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

 
We decided that the Plan does not have to waive the copayments for the SNF stays provided from November 7, 
2022, to November 30, 2022, and December 1, 2022, to December 8, 2022. 
 
You asked the Plan to waive the copayments for the SNF care. You say that the enrollee contracted COVID-19, 
which extended their SNF stay. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment for days 1 to 20 and a $100 copayment per day, for days 21 to 100 of the skilled 
nursing facility stay. 
 The enrollee has been asked to pay a $100 copayment per day, for days 21 to 24 of the SNF stay provided from 
November 7, 2022, to November 30, 2022. The enrollee has also been asked to pay a $100 copayment per day, 
for days 1 to 7 of the SNF stay provided from December 1, 2022, to December 8, 2022. The enrollee has been 
asked to pay a total of $1,100 ($100 copayment x 11 days = $1,100). These items/services fall within the 
skilled nursing facility care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
the SNF care provided from November 7, 2022, to November 30, 2022, and December 1, 2022, to December 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath or shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath or shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax for services provided on February 5, 2023. 
 
You asked the Plan to pay for the sales tax. You say that you feel this should be covered. You also say that the 
staff at the urgent care clinic referred you to the emergency room. The Plan denied your request. The Plan says 
sales tax is not covered on any of its products. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax for services provided on February 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
February 16, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the dental service 
provided 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 Plan's 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 service provided was exhausted on date of service February 9, 2021. Specifically, 
the Plan's contract provides coverage for one panoramic radiographic image or full mouth x-ray every five 
years. You previously received this service on February 9, 2021, less than five years prior, which was paid for 
by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that 
the Plan does not have to pay for the panoramic radiographic image (D0330) provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spirometry, including graphic record provided on December 
1, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for spirometry, including graphic record. You say that the services should be 
covered. The Plan denied your request. The Plan says this was not authorized. 
 
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 spirometry, including graphic record provided on 
December 1, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 3, 
2022, to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network doctor. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 3, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation and an ultrasound provided on 
February 06, 2023. 
 
You asked the Plan to pay for electrical stimulation and an ultrasound. You say that this service is supported in 
the records. 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 electrical stimulation 
and an ultrasound provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the primary care provider office visit 
provided on January 9, 2023. 
 
You asked the Plan to waive the deductible for the primary care provider office visit. You say that this is your 
primary care provider, and you should not have to pay to see them. 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. Your 
contract with the Plan says that there is a $625 deductible which applies to in-network primary care provider 
office visits. Your contract with the Plan also clearly says that you must pay a $0 copayment after meeting the 
deductible for in-network primary care provider office visits. 
 
 The item or service you asked the Plan to waive the deductible for falls within the in-network primary care 
provider office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $625 deductible which applies to in-network primary care provider office visits. This 
cost sharing is a contractual obligation that had not been met at the time the primary care provider office visit 
was received on January 9, 2023. Therefore, we decided that the Plan does not have to waive the deductible for 
the primary care provider office visit provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve OneTouch Verio test strips. 
 
You asked the Plan to pre-approve the OneTouch Verio test strips. You say that the enrollee has already been 
on OneTouch Verio test strips without issues. The Plan denied your request. The Plan says that the Plan does 
not cover this medication, it is non-preferred. 
 
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 no preferred brand of diabetic supplies and havent 
given any other reason to support the denial. The Evidence of Coverage (EOC), page 53 states for all people 
who have diabetes (insulin and non-insulin users). Covered services include: supplies to monitor your blood 
glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control 
solutions for checking the accuracy of test strips and monitors. The EOC does not list preferred products.  
Therefore, we decided that the Plan has to pre-approve OneTouch Verio test strips.  
 
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 the durable medical equipment provided on March 10, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for October 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0481 is 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. 
 In this case, the CPT Code Manual definition of code G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records show that 1-7 
drug classes were tested and there is a more appropriate code for these services. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code G0481 billed for October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on December 14, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a 
benefit. Medicare says tests with no 
relation to a diagnosis for the health of the patient are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that codes 82306 and 83036 are not a Medicare benefit for the diagnoses listed on the claim and are done 
for screening purposes. The enrollee has a listed diagnosis of neoplasm of the gallbladder. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services rendered 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 you would like reconsideration because the 
requested walk-in shower is medically necessary. The Plan denied your request. The Plan says the requested 
walk-in shower is not a covered benefit. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you have been hospitalized multiple time because of 
low glucose levels. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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. Our reviewer says that the 
coverage criteria for the CGM was not met. Our physician reviewer found that the enrollee is not taking insulin 
nor are they having low blood glucose sugar levels documented in the chart so criteria are not met for CGM 
coverage; furthermore, the enrollee is not on medications that cause low blood glucose levels; if indeed, the 
enrollee is having low blood glucose sugar levels, documentation of this should be submitted and the case re-
reviewed. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this therapy is the subject of ongoing clinical trials and is considered 
experimental. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for intravenous infusion of alpha 1 proteinase inhibitor rendered from July 
23, 2021, to October 29, 2021. 
 
You asked the Plan to pay for the services. You say that the submitted documents should be reviewed. The Plan 
denied your request. The Plan says that services that are experimental, investigational, cosmetic, or not 
generally recognized according to professional standards of safety and effectiveness are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has Alpha 1-Antitrysin deficiency disorder. The enrollee's serum level was 20. This 
medication was used in accordance with the Food and Drug Administration (FDA) labeling. The infusions 
were medically reasonable and necessary. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
intravenous infusion of alpha 1 proteinase inhibitor rendered from July 23, 2021, to October 29, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crown tooth 2 and 3 (D2751). 
 
You asked the Plan to pre-approve a crown for tooth 2 and tooth 3. You say that this is medically necessary for 
the enrollee The Plan denied your request. The Plan says your tooth has a lot of tooth missing from a cavity or 
from being broken and it can no longer be fixed with a filling. The x-rays your dentist sent show a crown is not 
needed to fix your tooth. 
 
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 Plan covers a crown for 
tooth 2 and tooth 3 when the services are medically necessary and reasonable.  
 
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 crown for tooth 2 and tooth 3. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the radiographs 
provided were inadequate to determine if there was significant coronal breakdown due to caries or fracture to 
warrant crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown for tooth 2 and tooth 3 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve white glass with metal crown tooth 2 and 3 (D2751).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 17, 2023. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, and 87653 billed for date of 
service July 25, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, and 87653. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, and 87653 is 
bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. While code 87150 was billed with modifier 59, the medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service. We 
have confirmed that code 87481 is a column II code to column I code 87150. We have confirmed that code 
87653 is a column II code to column I code 87150. 
 
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150, 87481, and 87653 billed for date of service July 25, 2022.