Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260) provided on January 4, 2023. 
 
You asked the Plan to pay for the semi-electric hospital bed. You say that the provider who supplied this item 
does not participate in Medicare. The Plan denied your request. The Plan says this item is not covered because 
the supplier is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare 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. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital 
bed have not been met. Therefore, we decided that the Plan does not have to pay for the hospital bed, semi-
electric (head and foot adjustment), with any type of side rails, with mattress (E0260) provided on January 4, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on October 18, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were rendered at 
an in-network facility and services were rendered on an emergency basis. The Plan denied your request. The 
Plan says that the members plan excludes coverage for this out-of-network service. 
 
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. The Plan has not provided a rule to substantiate their denial. Therefore, we 
decided that the Plan has to pay for subsequent nursing facility care provided on October 18, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 20, 2022, to 
February 18, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 20, 2022. The NOA was not received by the Plan until October 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from January 20, 2022, to February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says only the preferred 
brand products listed in the EOC are covered. In order to get the non-preferred diabetic supply, you can have 
the doctor send in a request for this supply as durable medical equipment (DME). It will then be covered at the 
DME co-payment level as listed in the Evidence of Coverage. 
  
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) and the 
extraspinal chiropractic manipulative treatment (98943) provided on February 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
  
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic manipulative treatments provided 
in this case are considered maintenance therapy as billed. Maintenance therapy is not a covered benefit. 
Additionally, extraspinal chiropractic manipulative treatment is not a covered benefit.   
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) 
and the extraspinal chiropractic manipulative treatment (98943) provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6058) for tooth #10 
and #11. 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the approval of D6058 for tooth for 
tooth #6, #8, #9, and #5. Therefore, we decided that the Plan does not have to pre-approve an abutment 
supported crown (D6058) for tooth #10 and #11.
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) 
sensor and reader. 
 
You asked the Plan to pre-approve the CGM sensor and reader. You say that the FreeStyle Libre would help 
the enrollee monitor levels on a more active basis. The Plan denied your request. The Plan says the enrollee 
does not require insulin three or more times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM sensor and reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 continuous glucose monitor (CGM) sensor and reader.
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 CGM is a medical necessity. The Plan denied 
your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the private swimming lessons (A9270) 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the private swimming lessons 
purchased are not covered under the Wellness allowance benefit. Therefore, we decided that the Plan does not 
have to issue reimbursement for the private swimming lessons (A9270) purchased on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the sales tax applied to the gym membership 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
  
The Plans rules for coverage of gym benefits have not been met because the sales tax applied to the gym 
membership purchased is not payable. The Plan contract states that sales tax is not eligible for reimbursement 
under the wellness allowance benefit. The Plan previously issued payment to you on January 6, 2023 for the 
gym membership purchased. Therefore, we decided that the Plan does not have to issue reimbursement for the 
sales tax applied to the gym membership purchased on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
13, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established 
patient (D0150), and unspecified adjunctive procedure, by report (D9999) provided on August 22, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you feel you should be approved for the 
out-of-network services.  The Plan denied your request. The Plan says dental services from an out-of-network 
provider 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. 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the record shows you received the dental services from a non-participating oral 
surgeon. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation - 
new or established patient (D0150), and unspecified adjunctive procedure, by report (D9999) provided on 
August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and semi-
precision attachment  placement (D6192). 
 
You asked the Plan to pre-approve the dental services. You say that you were recently in an accident and lost 
your dentures. The Plan denied your request. The Plan says your benefit for the complete denture - mandibular 
has already been exhausted. The semi-precision attachment  placement is not listed as covered under the 
Plans dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the complete denture - mandibular was exhausted on date of service June 9, 2022. The 
semi-precision attachment  placement (D6192 is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and semi-
precision attachment  placement (D6192).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
14, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on September 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 1, 2022, billed with 
code 0241U. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
provided on December 1, 2022, billed with code 0241U.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home sleep test with portable monitor provided on 
December 12, 2022. 
 
You asked the Plan to pay for a home sleep test with portable monitor. You say that this is supported in the 
records. 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 home sleep test with 
portable monitor provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on December 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 18, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation - established patient (D0120). 
 
You asked the Plan to pre-approve the dental services. You say that for medical reasons and the medications 
you take for those reasons, you would like to stay with your current provider. The Plan denied your request. 
The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a periodic 
oral evaluation - established patient (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronectomy (code 41899). 
 
You asked the Plan to pre-approve the dental service. You say that the requested coronectomy is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because there was no proper procedure names or billing codes for the requested dental 
service. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
coronectomy (code 41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
on December 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you should not be 
responsible for the copay due to the quality of care you received. The Plan denied your request. The Plan says 
this claim was processed correctly per the Plans benefits for vision care. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you received a diagnostic eye exam on this 
date of service. Based on this information, we decided that the Plan's rules for coverage of the outpatient office 
visit have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient office visit (99213) provided on December 28, 2022.   
Your complaint about being given the wrong prescription and having to make multiple visits is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.