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

 
We decided that the Plan does not have to pay for durable medical equipment provided on July 25, 2023. 
 
You asked the Plan to pay for durable medical equipment. You say that you had to purchase this equipment. 
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 durable medical 
equipment provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on June 23, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and would like the claim processed. 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 a valid proof of delivery. Specifically, there is no proof of delivery to show that the 
CGM and related supply allowance was received by the enrollee. 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 a continuous glucose monitor (CGM) and the related supply allowance provided by an out-of-
network provider on June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a heart procedure provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for a heart procedure. You say that you should not owe this 
copayment, you cannot afford it. 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 $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for a heart procedure. This item/service falls within the 
outpatient hospital services 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 a heart 
procedure provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on June 28, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you are requesting a reprocess of 
the claim. The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a durable 
medical equipment supplier. 
 
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 the supply allowance for a continuous 
glucose monitor (CGM) provided on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel test provided on August 31, 2023. 
 
You asked the Plan to pay for the urine panel test. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine panel test provided on August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen concentrator to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve oxygen concentrator. You say that you do not agree with the denial for the 
oxygen concentrator. The Plan denied your request. The Plan says the service can be provided by an in-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 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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 oxygen concentrator to be provided by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83880 for date of service August 24, 2023. 
 
You asked the Plan to pay for procedure code 83880. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83880 is assay of Natriuretic peptide. 
 We find that CPT code 83880 is not supported in the medical record. Specifically, no medical records were 
submitted. This means medical necessity of the services rendered cannot be verified. Based on this information, 
we decided that Medicare rules for coverage of procedure code 83880 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83880 for date of service August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transperineally implanted periureteral adjustable balloon 
continence device. 
 
You asked the Plan to pre-approve transperineally implanted periureteral adjustable balloon continence device. 
You say that you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan 
says there is not enough research to show that this requested item improves net health outcomes for people with 
urinary incontinence. 
 
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 transperineally implanted periureteral 
adjustable balloon continence device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided medical records and review of the current peer-reviewed medical literature do not document that use of the transperineally 
implanted periureteral adjustable balloon continence device has been shown in controlled studies in a 
Medicare-approved journal to result in sustained long term health benefits in the Medicare population with post 
prostatectomy stress urinary incontinence as described in this clinical scenario when compared to other 
standard treatment options such as placement of an artificial urinary sphincter or a male sling procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transperineally implanted periureteral adjustable balloon continence device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve transperineally implanted 
periureteral adjustable balloon continence device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92012) provided on August 17, 
2023. 
 
You asked the Plan to pay for a medical eye examination (92012). You say that the referral was authorized by 
the Plan as there were no cataract surgeons near your home. 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). The record shows that the services were not approved in advance. Therefore, we 
decided that the Plan does not have to pay for a medical eye examination (92012) provided on August 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (A4239, E2103) provided on August 3, 
2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the provider is not eligible for Medicare payment. 
 
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 diabetic supplies (A4239, E2103) 
provided on August 3, 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).  
You asked the Plan to pre-approve a CGM. You say that a CGM would help you. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. 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 
Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a color accent (K0108) for an approved power 
wheelchair. 
 
You asked the Plan to pre-approve the color accent feature. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says this is an aesthetic feature and does not serve a medical purpose. 
 
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 color accent (K0108) for an approved power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835) and 
additional items and accessories (codes E0955, E0973, E0978, E1002, E1028, E2310, E2343, E2361, E2609, 
E2617, and K0040). 
 
  You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that this durable medical equipment (DME) will promote independent mobility, alleviate joint and 
back pain, help manage edema, and provide independent self-pressure relief and optimal positioning for safe 
swallowing and participation in daily routines. The Plan denied your request. The Plan says they have 
confirmed with the facility they are a licensed SNF. The Plan also say the Medicare DME benefit does not 
cover DME in a SNF therefore wheelchair is never covered at members present location 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a group 2 standard power wheelchair and additional items and accessories is being requested 
for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a group 2 
standard power wheelchair (K0835) and additional items and accessories (codes E0955, E0973, E0978, E1002, 
E1028, E2310, E2343, E2361, E2609, E2617, and K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push wheelchair with accessories. You asked the Plan 
to pre-approve a push wheelchair with accessories. You say that the enrollee has a significant medical and 
postural need for these items. The Plan denied your request. The Plan says durable medical equipment is not 
covered because this enrollee is in a SNF. The Plan must follow Medicare rules. The rules say that for 
equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not 
consider a SNF or a hospital to be a home. Records show that a push wheelchair with accessories is being 
requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a push 
wheelchair with accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve baroreflex activation device. 
 
You asked the Plan to pre-approve baroreflex activation device. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is still being studied to see 
if the treatment is reasonable and necessary. 
 
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 baroreflex activation device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in August 2019 the Food and Drug Administration approved the 
system for use in patients with refractory heart failure who remain symptomatic despite treatment with 
guideline-directed medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal 
daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains 
an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the 
value of Barostim Neo in patient 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 baroreflex activation device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve baroreflex activation device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure. 
 
You asked the Plan to pre-approve intracept procedure. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says it is experimental or has not been proven to be safe. 
 
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 intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. 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 a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on September 22, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you dont 
feel you should be responsible for the cost share applied on the claim because this is more than you had paid in 
the past. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for the computed tomography (CT) scan. 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. However, since the allowed amount is 
less than the standard copayment, you only owe $168.43. Therefore, we decided that the Plan does not have to 
waive the copayment for the computed tomography (CT) scan provided on September 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain or ceramic crown (D2740). 
 
You asked the Plan to pre-approve porcelain or ceramic crown. You say that after viewing the radiographs 
taken, and doing the physical examination, you discovered that tooth number 9 was compromised due to a chip 
on implant crown. You also say that it can be restored with a new crown. The Plan denied your request. The 
Plan says the criteria for porcelain or ceramic crowns (D2740) has not been met because plan exclusions do not 
cover any implant related services, including crowns. 
 
  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 porcelain or 
ceramic crown when the services are medically necessary and reasonable.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of porcelain or ceramic crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve porcelain or ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 27, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. 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 a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 27, 2023.