Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusion pump provided on February 21, 
2023. 
 
You asked the Plan to waive the coinsurance for infusion pump. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for infusion pump. This item/service falls within the durable 
medical equipment (DME) and related 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. The total you owe is $70.25 ($351.27 allowed amount x 20% = 
$70.25). Therefore, we decided that the Plan does not have to waive the coinsurance for infusion pump 
provided on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 66984-LT billed for July 5, 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 the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that the -54 modifier is billed for surgical care only and the 
-55 modifier is billed for postoperative management only when physicians agree on the transfer of care during 
a global surgical period. 
 
We looked at the file and Medicare rules. The file shows that procedure code 66984-LT was billed with both 
the -54 and -55 modifiers. The services cannot be paid with both modifiers billed for the services. Therefore, 
we decided that the Plan does not have to pay for procedure code 66984-LT billed for July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the enrollee has severe diabetic 
neuropathy which limits mobility and feeding, lacks dexterity to safely use traditional glucometer and test 
strips. The Plan denied your request. The Plan says that  the enrollee does not meet Medicare criteria. 
 
The Plan must follow 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 a Freestyle Libre 2 sensor. Our 
reviewer says that the item is medically necessary. Our physician reviewer found that the enrollee had a severe 
low blood sugar reaction requiring emergency medical technicians (EMTs). The records state it is also hard for 
the enrollee to use a handheld glucometer requiring fingerstick. Therefore, criteria for a CGM have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre 2 sensor have been met. Therefore, we decided that the Plan 
has to pre-approve a Freestyle Libre 2 sensor.  
 
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 pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. 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 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM require 
insulin use or low blood sugar. The enrollee is not having low blood sugar and is not using insulin. If the 
enrollee begins insulin, the case should be reviewed; we are not told why fingerstick monitoring would not 
suffice for the enrollee now. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
November 17, 2020. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you had this 
service during covid and it should be covered without a copayment. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance 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 an in-
network ambulance ride provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that prior authorization is not needed for this 
service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on February 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on January 17, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a molecular pathology procedure. 
 
You asked the Plan to pre-approve the services. You say that you are at risk for spinocerebellar ataxia (SCA) 
type II. The Plan denied your request. The Plan says the records do not show any signs or symptoms associated 
with disease. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have a family history of spinocerebellar ataxia in mother and sister. Records indicate that you do 
not have any symptoms or signs associated with the disease, but the provider would like to perform the 
comprehensive ataxia panel tests as part of screening. The review has determined that  the enrollee does not 
meet the criteria for this testing. 
 
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 pre-approve a molecular pathology procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drug, Imbruvica. 
 
You asked the Plan to pre-approve Imbruvica. You say that you need the requested medication to treat your 
current medical condition. The Plan denied your request. The Plan says the requested drug is on the self-
administered drug list and is excluded from coverage under Part B. 
 
 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 the self-administered drug, 
Imbruvica.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on October 28, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
stay provided on October 28, 2022, to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 9, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87798 rendered 
on January 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported these 
procedure codes with the appended modifier XU - unusual non-overlapping services. The laboratory report 
does not include any documentation to support the code and modifier reported. Therefore, these codes cannot 
be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87481, 87641, and 87798 rendered on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88189 provided on January 6, 2023. 
 
You asked the Plan to pay for procedure code 88189. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. The rules say that for purposes of payment under the Medicare Physician 
Fee Schedule (MPFS), the place of service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. However, there are two exceptions to this general rule  these are 
for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88189 have not been met. The file shows that the enrollee was registered as an 
inpatient of a hospital on the date of service procedure code 88189 was provided. The office POS code on the 
claim is inappropriate in this case. Therefore, we decided that the Plan does not have to pay for procedure code 
88189 provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous therapeutic infusions provided on 
January 3, 2023. 
 
You asked the Plan to pay for intravenous therapeutic infusions. You say that the services were medically 
necessary. The Plan denied your request. The Plan says an appeal was submitted by the provider with no new 
medical records. Documentation submitted on appeal consists of duplicates of medical documents previously 
reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of intravenous therapeutic infusions have 
been met. Therefore, we decided that the Plan does not have to pay for intravenous therapeutic infusions 
provided on January 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on October 24, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service 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 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 nursing facility care provided on October 24, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that the enrollee meets Medicare 
criteria. The Plan denied your request. The Plan says that the Freestyle Libre 3 sensor is not a Medicare-
covered product. 
 
The Plan must follow 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 a Freestyle Libre 3 sensor. Our 
reviewer says that the item is medically necessary. Our physician reviewer found that the enrollee is using 
insulin; therefore, Medicare criteria for CGM use has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre 3 sensor have been met. Therefore, we decided that the Plan 
has to pre-approve a Freestyle Libre 3 sensor.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you require SNF services to regain your prior level 
of functioning. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 04, 2023, to April 
10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on April 04, 2023, to April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 18, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 18, 2023.