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

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
April 25, 2023. 
 
You asked the Plan to pay for the billed testing. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes. We find that CPT codes 80307 and G0483 are not 
supported in the medical record. The medical records provided do not include lab results of the billed testing. 
Based on this information, we decided that Medicare rules for coverage of the billed testing have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date 
of service April 25, 2023.
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 need daily wound care on both feet, and do not 
have the proper care at home. The Plan denied your request. The Plan says you no longer require skilled 
services on a daily inpatient basis and the continuation of SNF care 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 there are no identifiable skilled nursing or skilled therapy service needs. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services should be covered. The Plan denied your request. The Plan says without transport there are no 
payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on October 3, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there are 
no covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 3, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on October 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay. provided on April 13, 2023, to 
April 18, 2023. 
 
You asked the Plan to pay for an inpatient hospital stay.. 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 an inpatient hospital 
stay. provided on April 13, 2023, to April 18, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the arm joint. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary due to your 
severe pain. The Plan denied your request. The Plan says that the medical records do not support a need for an 
MRI at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found with the chronic pain, decreased range of motion 
and the calcifications in the rotator cuff, there are valid indications for an MRI of the right shoulder. The MRI 
should 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the arm joint.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care. provided on May 18, 2023. 
 
You asked the Plan to pay for initial nursing facility care.. You say that there are currently no in-network  
providers who can treat patients in this facility. 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 initial nursing facility 
care. provided on May 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on August 17, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records attached support these services. 
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 skilled nursing facility 
provided on August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not support that the enrollee uses insulin or 
has a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on April 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there is 
no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on April 28, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed services provided on September 23, 2022. 
 You asked the Plan to pay for the hospital bed services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 13, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital bed 
services provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on February 15, 2023, to June 
27, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that the provider was not responsible to obtain 
authorization for the services. 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 nursing facility care. 
provided on February 15, 2023, to June 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services. provided on August 03, 2023. 
 
You asked the Plan to pay for ambulance services.. You say that no other mode of transportation was 
appropriate for the enrollee. 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 ambulance services. 
provided on August 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on August 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 August 1, 2023. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2740) provided on August 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2335) provided on July 31, 2023. 
 
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 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 a filling (D2335) provided on July 31, 2023.
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 wipes are necessary. The Plan 
denied your request. The Plan says the requested items 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-network benefit level for out-of-network care 
with a surgeon. 
 
You asked the Plan to pre-approve the in-network benefit level for out-of-network care with a surgeon. You 
say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the 
requested services are available with in-network providers if you would like to pay the in-network benefit level.  
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 $60 
copayment for specialist services with an out-of-network provider.  
 
We looked at the file, the plan's contract, and Medicare rules. In this case, the plan's contract clearly states the 
enrollee has out-of-network benefits and can be seen by out-of-network providers at a higher cost share. The 
plan does have in-network surgical specialists available to the enrollee if the enrollee would rather pay the in-
network rate. Therefore, we decided that the Plan does not have to pre-approve the in-network benefit level for 
out-of-network care with a surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections (64493, 64495) provided on July 11, 
2023. 
 You asked the Plan to pay for the injections. You say that the enrollee was seen at the surgery center due to 
lumbar spondylosis. The Plan denied your request. The Plan says the enrollee did not meet the LCD coverage 
criteria.  
 
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 pay for the injections. Our reviewer says that the 
facet joint injections are not medically necessary. Our physician reviewer found that the LCD criteria requires 
that there are no other probable causes of her back pain. However, there is documentation of radiculopathy, 
lumbar region, that could explain the source of the enrollee's pain as well as spinal stenosis and multi-level disc 
extrusion and protrusion. Furthermore, absence of untreated radiculopathy, neurogenic claudication, or non-
facet pathology that could explain the source of the enrollee's pain is required for Medicare coverage. 
Therefore, the procedure does not meet the LCD coverage criteria, and is not medically reasonable and 
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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for the facet joint injections (64493, 64495) provided on July 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician 
management with close medical monitoring and cannot be adequately care for in their current condition at a 
skilled nursing facility. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand-held low vision aid and the sales tax provided on 
July 31, 2023. 
 
You asked the Plan to pay for the hand-held low vision aid and the sales tax. You say that you want to be 
refunded the full amount. The Plan denied your request. The Plan says the Plan has paid $150 towards the 
hand-held low vision aid which has exhausted the benefit. The sales tax is not a covered benefit. 
 
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. The Plan covers these services when reimburses up to $150 every year for non-Medicare covered 
prescription eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid a total of $150 towards the services which 
exhausted the benefit. The sales tax is not a covered benefit. Based on this information, we decided that the 
Plan's rules for coverage of the hand-held low vision aid and the sales tax have not been met. Therefore, we 
decided that the Plan does not have to pay for the hand-held low vision aid and the sales tax provided on July 
31, 2023.