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

 
We decided that the Plan does not have to reduce the coinsurance for the insulin injection provided on July 16, 
2022. 
 
You asked the Plan to reduce the coinsurance for the insulin injection. You say that you do not know why there 
was an increase for the insulin. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the insulin injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total you owe is $209.63 ($1,048.13 allowed amount x 20% = $209.63). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the insulin injection provided 
on July 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on December 2, 2022, to 
December 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for occupational therapy. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says prior authorization 
is required for any subsequent visits. 
 
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 occupational therapy provided on December 2, 
2022, to December 8, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service October 27, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 is bundled 
into payment for code 87801. 
 
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 codes 
87481, 87653, and 87798 are a column II code to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct procedural 
service. 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 87481, 87653, and 87798 billed for date of service October 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic treatments provided from January 27, 2021, 
to December 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic treatments. You say that you were not aware that you needed a 
referral for these services. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 the chiropractic treatments provided from January 
27, 2021, to December 31, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation to and from a colonoscopy procedure. 
 
You asked the Plan to pre-approve the transportation. You say that you assumed transportation to appointments 
other than your primary care physician were covered. The Plan denied your request. The Plan says the service 
is not a covered 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 routine transportation when unlimited rides to your Primary Care Provider's office.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transportation to and from a colonoscopy procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lorazepam. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Lorazepam.   
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to receive therapy services to return to their prior level of function. The Plan denied your request. The Plan says 
the enrollee does not require therapy or nursing services on a daily basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 Sensor. You say that after three years all of a sudden no one 
will pay for the Dexcom anymore. The Plan denied your request. The Plan says your do 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom 
G7 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
Sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency 
transport provided on November 2, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that you paid out of pocket for the services. You 
also say that you were unaware of the option to submit a reimbursement request. The Plan denied your request. 
The Plan says the claim was not filed within the one year deadline and neither was the member reimbursement 
request. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance service was not filed until January 17, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport 
provided on November 2, 2020.
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 February 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was called due to your fainting and low blood pressure. You also say you were advised by the 
ambulance crew you did not need to be transported. 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 February 12, 2023. 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 February 12, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on October 
19, 2022. 
 
You asked the Plan to pay for the evaluation and management services. You say that the enrollee was not on 
hospice on this date. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 18, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for evaluation and 
management services provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), polycarbonate or equal 
lenses (V2784), and single vision lenses (V2100) purchased on August 5, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, polycarbonate or equal lenses, and single vision 
lenses. You say that you were not told that you would have a copay, and you do not agree to owing the bill of 
$120.00. The Plan denied your request. The Plan says you had previously used your two-year allowance on 
May 20, 2021, and you were not yet eligible for another allowance. 
 
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 a $150 single purchase allowance every 2 years for eyewear. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you had previously used your two-year 
allowance on May 20, 2021, and your eyewear benefit had been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the anti-reflective coating, polycarbonate or equal lenses, and 
single vision lenses have not been met. Therefore, we decided that the Plan does not have to pay for the anti-
reflective coating (V2750), polycarbonate or equal lenses (V2784), and single vision lenses (V2100) purchased 
on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Poliovirus vaccine provided on August 25, 2022, and September 26, 2022.

You asked the Plan to pay for the Poliovirus vaccine. You say that this was a preventive vaccine that your doctor recommended for Polio. The Plan denied your request. The Plan says the Poliovirus vaccine is not a non-covered Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that the Poliovirus is not a disease entity endemic in the United States and therefore the vaccine is not covered by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Poliovirus vaccine have not been met. Therefore, we decided that the Plan does not have to pay for a Poliovirus vaccine provided on August 25, 2022, and September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 99152. You say that the services at issue are billed correctly. The 
Plan denied your request. The Plan says the provided records do not support the services at issue. 
 
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 99152 is: Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the provided records do not 
support the presence of an independent trained observer to assist in the monitoring of the enrollee's level of 
consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99152 billed for date of service October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of procedure code 83036 billed for date of 
service April 28, 2022. 
 
You asked the Plan to pay for procedure code 83036. You say that You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 83036 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 83036 have not been met. Therefore, we decided that the Plan does not have to pay for a 
second unit of procedure code 83036 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98941) provided from October 8, 2015, through December 31, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services at 
issue are not payable as the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until January 10, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed.  
  
Therefore, we decided that the Plan does not have to issue reimbursement for the chiropractic manipulative 
treatments (98941) provided from October 8, 2015, through December 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG); recording in coma or sleep 
only (95822) provided on November 23, 2021. 
 
You asked the Plan to pay for the EEG. You say that the claim should be paid as billed. The Plan denied your 
request. The Plan says some of the billed services were approved on the appeal; however, procedure code 
95822 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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
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 EEG. Our reviewer says that the documentation does not 
support procedure code 95822.  Our reviewer found that after review of the documentation, procedure code 
95822 is not supported.  
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for an electroencephalogram (EEG); recording in coma or sleep only (95822) provided on November 23, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implant of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the CardioMEMS device has not been demonstrated in the peer-reviewed literature. 
 
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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system (CardioMEMS) for management of CHF in this enrollee. The 
CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope (1). Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device (2). In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the transcatheter implant of wireless pulmonary artery pressure sensor 
(CardioMEMS) (33289).