Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department services provided from October 24, 2023, to 
October 25, 2023. 
 
You asked the Plan to pay for emergency department services. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan did not provide a reason for 
denial.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan failed to provide a valid reason to deny the services 
performed. Therefore, we decided that the Plan has to pay for emergency department services provided from 
October 24, 2023, to October 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on June 30, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
information needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and the fundus photography 
provided on June 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye examination and the fundus photography. You say that the 
services were medically necessary. The Plan denied your request. The Plan says 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 had network providers 
available who could have provided the medical eye examination and the fundus photography. The Plan did not 
pre-approve the medical eye examination and the fundus photography. 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 medical eye examination and the fundus photography provided on June 8, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cold pad (E0218) provided on April 6, 2023 to April 25, 
2023. 
 
You asked the Plan to pay for the cold pad (E0218). You say that this item was medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item billed is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the cold pad (E0218) have not been met. 
Therefore, we decided that the Plan does not have to pay for a cold pad (E0218) provided on April 6, 2023 to 
April 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 6, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have been seeing this doctor every other 
week for the last year and the payments have been made by the insurance. You say that you do not believe you 
should be liable for anything other than your copay. The Plan denied your request. The Plan says the service 
was rendered by an opt-out provider.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy, allograft, 
morselized, or placement of osteopromotive material, for spine surgery only, and arthrodesis, anterior interbody 
technique, including minimal discectomy to prepare interspace (63047, 63048, 20930, 22558). 
 
You asked the Plan to pre-approve laminectomy, facetectomy and foraminotomy, allograft, morselized, or 
placement of osteopromotive material, and arthrodesis. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve laminectomy, facetectomy and 
foraminotomy, allograft, morselized, or placement of osteopromotive material, and arthrodesis. 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 correlation between imaging studies showing severe nerve root 
compression and physical exam findings showing neurological deficit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laminectomy, facetectomy and foraminotomy, allograft, morselized, or 
placement of osteopromotive material, and arthrodesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laminectomy, facetectomy and foraminotomy, allograft, morselized, or placement 
of osteopromotive material, for spine surgery only, and arthrodesis, anterior interbody technique, including 
minimal discectomy to prepare interspace (63047, 63048, 20930, 22558).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 23, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have been seeing this doctor every other 
week for the last year and the payments have been made by the insurance. You say that you do not believe you 
should be liable for anything other than your copay. The Plan denied your request. The Plan says the service 
was rendered by an opt-out provider.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on May 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from September 30, 
2022, to October 12, 2022. 
 
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 a corrected itemized bill was not received. 
 
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 the services have been met. Despite 
multiple requests from the plan, a corrected itemized bill has not been received. The charges on the itemized 
bill ($322,474.01) and the UB-04 ($322,293.01) do not match. An accurate itemized bill is needed to verify the 
services. Therefore, we decided that the Plan does not have to pay for inpatient hospital services rendered from 
September 30, 2022, to October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on June 29, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all the necessary documents 
required for payment. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
repair resin partial denture base, mandibular (D5611) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you went to the provider for the services 
you were informed that they were out-of-network. You also say that the provider spoke with someone from the 
plan and the plan stated they would cover the bill. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation - problem focused (D0140), and repair resin partial denture base, 
mandibular (D5611) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and the non-intravenous conscious 
sedation (D9248) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed extractions after having cancer 
treatment and attempted to go in-network for services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the extraction (D7210) and the non-intravenous conscious sedation (D9248) provided on August 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81456) provided on August 29, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a Next Generation Sequencing (NGS) test to 
be covered, the test must have Food & Drug Administration (FDA) approval or clearance as a companion in 
vitro diagnostic; and, an FDA-approved or cleared indication for use in that patients cancer. 
 
We looked at the file and Medicare rules. The Tempus xR test is not FDA approved for this use. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81456) provided on August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0012M) provided on May 19, 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 29, 2023. 
 
You asked the Plan to pay for the supply allowance for the CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and 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 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-implanted continuous glucose monitor (CGM), supply 
allowance and accessories provided on July 18, 2023. 
 
You asked the Plan to pay for the CGM, supply allowance and accessories. You say that you have submitted 
proof of delivery along with other supporting documentation, but the claim keeps denying for missing this 
information. The Plan denied your request. The Plan says the provider is not a plan contract provider and 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 a non-implanted continuous glucose 
monitor (CGM), supply allowance and accessories provided on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-implanted continuous glucose monitor (CGM), supply 
allowance and accessories provided on June 29, 2023. 
 
You asked the Plan to pay for the CGM, supply allowance and accessories. You say that you have submitted all 
supporting documentation. The Plan denied your request. The Plan says the provider is not a plan contract 
provider and 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 a non-implanted continuous glucose 
monitor (CGM), supply allowance and accessories provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110). 
 
You asked the Plan to pre-approve complete upper dentures. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete upper dentures (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
June 30, 2023. 
 
You asked the Plan to pay for 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 the rendering provider is not 
enrolled with Medicare. 
 
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 a continuous glucose monitor (CGM) 
(A4239) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for transplant related lodging, meals, and transportation provided on 
September 25, 2023. 
 
You asked the Plan to pay for transplant related lodging, meals, and transportation. You say that you were 
advised multiple times that you can receive reimbursement for mileage. The Plan denied your request. The Plan 
says that the documentation required for processing has not been received. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the plan has not provided any information showing the guidelines 
for requesting reimbursement, and the Plan has not appeared to provide the actual reimbursement request.  
Therefore, we decided that the Plan has to pay for transplant related lodging, meals, and transportation 
provided on September 25, 2023. 
  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl Graft (Q4210), Celera Dual Layer (Q4259), and 
Helicoll (Q4164). 
 
You asked the Plan to pre-approve Axolotl Graft, Celera Dual Layer, and Helicoll. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Axolotl Graft, Celera Dual Layer, and 
Helicoll. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation did not clearly show the 
enrollee having fully exhausted first line treatment for his wound including stopping smoking and good diabetes control via lifestyle changes and medications. No A1C% or other testing revealed whether or not his 
diabetes was in good control. Also, the above products specifically do not have sufficient high-quality evidence 
to support their use in this clinical situation to justify this request at this time. Therefore, the Axolotl Graft 
(Q4210), Celera Dual Layer (Q4259), and Helicoll (Q4164) will each be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Axolotl Graft, Celera Dual Layer, and Helicoll have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Axolotl Graft (Q4210), Celera Dual Layer (Q4259), and 
Helicoll (Q4164).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a support garment (A4467) provided on July 26, 2023. 
 
You asked the Plan to pay for the support garment. You say that this item was medically necessary. The Plan 
denied your request. The Plan says this is a non-covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments (A4467) 
with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or 
semi-rigid devices. Code A4467 is denied as non-covered. 
 
We looked at the file and Medicare rules. The support garment at issue is non-covered under Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the support garment have not been 
met. Therefore, we decided that the Plan does not have to pay for a support garment (A4467) provided on July 
26, 2023.