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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
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 
item is not medically necessary. Our physician reviewer found the items denied correctly as you do not meet 
the clinical requirements to be approved. 
 
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) (A4239).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 25, 
2022, through February 23, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says there were no daily skilled nursing or therapy services needed.  
 
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 pay for 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 did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or 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 pay for skilled nursing facility (SNF) care provided from January 25, 2022, through February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and related services 
provided on December 15, 2022. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and related services. You say that these 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 a hospital outpatient 
clinic visit, and related services provided on December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that you disagree with the Plan's denial. 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 Nexletol.   
Benefits for Nexletol 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.  
You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that this is a medical necessity. The 
Plan denied your request. The Plan says you do not meet criteria for a Freestyle Libre 2 sensor. 
 
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 Freestyle Libre 2 sensor. Our 
reviewer says that the Freestyle Libre 2 sensor is not medically necessary. Our physician reviewer found the 
provided criteria require the differential diagnosis of diabetes mellitus for CGM coverage along with blood 
glucose sugar or insulin use. You do not have diabetes mellitus and there is no good description of the severity 
of the low blood glucose episodes you are having in order to confirm these are level 2 blood glucose drops. 
Criteria are hence not 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 the Freestyle Libre 2 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of entropion. 
 
You asked the Plan to pre-approve repair of entropion. You say that repair of entropion is medically necessary. 
The Plan denied your request. The Plan says the requested repair of entropion does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that eyelid surgeries may be considered reconstructive in 
nature for the following indications where there is functional impairment as documented by preoperative frontal and lateral photographs: entropion.  
 
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 repair of entropion. Our reviewer says 
that the requested repair of entropion is not considered medically necessary in this case. Our physician reviewer 
found that there are no preoperative photos provided for review to document the eyelid pathology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of entropion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs 
operation).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you would mainly use the power scooter in the 
local community. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 23, 2022, billed with 
codes 87150, 87481, and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you disagree with the Plan's denial. 
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 is a test panel it should be 
characterized by a single unit of service. 
 
 
 We looked at the file and Medicare rules. This was a 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 laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on June 23, 2022, billed with codes 87150, 87481, and 87798.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 06, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay for an ambulance. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance services. 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 the ambulance 
services provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on March 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the eye exam. You say that it was the facility's responsibility to obtain 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained, and the 
provider was out-of-network. 
 
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 
eye exam. We found no exception that would require the Plan to pay for the eye exam. Therefore, we decided 
that the Plan does not have to pay for the eye exam provided on March 20, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6.  
You asked the Plan to pre-approve a Dexcom G6. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Dexcom G6. Our reviewer says that 
the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee uses Janumet and Glipizide. The documentation does not contain 
documentation about the enrollee's blood glucose sugar levels. The documentation does not support low blood 
glucose levels or that the enrollee uses insulin. Therefore, the enrollee does not meet criteria for the requested 
device. 
 
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 Dexcom G6 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73120-26-RT billed for date of service 
February 6, 2023. 
 You asked the Plan to pay for procedure code 73120-26-RT. You say that the patient had multiple exams on 
this date of service. The Plan denied your request. The Plan says payment for code 73120-26-RT is bundled 
into payment for code 73130-26-RT. 
 
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 
73120-26-RT is a column II code to column I code 73130-26-RT. 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 code 73120-26-RT billed for date 
of service February 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 5, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service December 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on April 03, 2023. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you did not use 
an observation room during this visit. 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 $300 
copayment for in-network outpatient hospital observation. 
 
You have been asked to pay a $300 copayment for the hospital observation services. This item/service falls 
within the in-network outpatient hospital observation 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 record shows this claim was approved and you are 
responsible for the cost share amount. However, since the allowed amount is less than the standard copayment, 
you only owe $115.18. Therefore, we decided that the Plan does not have to waive the copayment for the 
hospital observation services provided on April 03, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Triluron. 
 
You asked the Plan to pre-approve Triluron. You say that the requested Triluron is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Triluron. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of drug 
Orthovisc OR Supartz FX first before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Triluron have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Triluron.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83721 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 83721. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83721 is bundled into payment for code 80061. 
 
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 83721 
is a column II code to column I code 80061. 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 code 83721 billed for date of service November 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic door opener. 
 
You asked the Plan to pre-approve an automatic door opener. You say that you are unable to open your own 
door to get to appointments and to let your caregiver in. The Plan denied your request. The Plan says this item 
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 an automatic door opener.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are expensive. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 & 87653 billed for date of service 
December 21, 2022. 
 You asked the Plan to pay for procedure codes 87481 & 87653. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 87481 & 87653 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 are column II codes to column I code 87801. 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 87481 & 87653 billed for date of 
service December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 24, 2023. 
 
You asked the Plan to pay for the home health services. You say that this services was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the home health services are not supported in the record. Specifically, the claim was billed with 
Type of Bill 130. A type of bill ending in zero represents a non-payment claim. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for home health services provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service October 18, 
2022.  
 
You asked the Plan to pay for procedure code 99231. You say that these services were provided by separate 
providers. The Plan denied your request. The Plan says payment for code 99231 is bundled into payment for 
code 99233. 
 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 99231 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 code 99231 billed for date of service October 18, 2022.