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

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on 
October 3, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare for 
diabetes or a renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6240, D6750 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has a severe gag reflex and 
would benefit from a bridge to fill in the space of the extracted tooth. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. The Plan's rule for coverage states that the 
placement of a fixed prosthetic appliance will only be considered for cases where there is a documented 
physical or neurological disorder that would preclude placement of a removable prosthesis. 
 
 
  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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that radiographs were not provided 
with the documentation. These are required to determine if the abutment retainers have adequate bone support 
and to determine if other teeth are missing in the arch. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge (D6240, D6750 x 2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 17, 2022, to 
February 15, 2022 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was billed timely. 
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 November 18, 2021. The NOA was not received by the Plan until February 
7, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that it appears that you submitted the NOA to Original Medicare in November 
of 2021.  However, you were required to submit the NOA to the Plan. Therefore, we decided that the Plan does 
not have to pay for home health services provided from January 17, 2022, to February 15, 2022
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service November 5, 
2022, to November 9, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you have a contract and you are allowed to 
bill this code. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service November 5, 2022, to November 9, 2022.
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). 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does 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 record indicates that the enrollee has 
diabetes.  The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. 
 
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 freestyle libre 2 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 11, 2023, billed with 
code 78815-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed without the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that a different cancer diagnosis whether submitted 
with a PI or a PS modifier will begin the count of one initial and three subsequent FDG PET scans.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. This service was billed without the required PI 
or PS modifier and is not payable. Therefore, we decided that the Plan does not have to pay for imaging 
services provided on January 11, 2023, billed with code 78815-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on January 24, 2023.  
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says with the 
information we have, we cannot determine how the member came to the servicing provider, or whether the 
services are medically necessary. 
 
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 duplex scan have been met. 
Therefore, we decided that the Plan does not have to pay for a duplex scan provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. The Plan's rule for coverage state's that 
your tooth must have noticeable bone loss or show on an x-ray that there is a hard substance built up on the 
root of the tooth.  
 
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 dental services. Our reviewer says 
that the request is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not indicate appreciable bone loss or the presence of subgingival calculus. Also, there was 
no record of the charting of periodontal pockets showing pathology.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planning (D4341 x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 for 
February 28, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 for 
February 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency room services provided on 
January 11, 2023. 
 
You asked the Plan to reduce the copayment for the emergency room services. You say that this was an urgent 
care 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for the emergency room services. This item/service falls within 
the emergency care 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 reduce the copayment for the emergency room 
services provided on January 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 19, 2022, billed with 
code 76706-26. 
 
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 diagnosis is not consistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for Abdominal Aortic Aneurysm for beneficiaries who meet the required criteria.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. This claim was billed with a diagnosis of Z13.6 
which does not meet the requirements for the procedure. Therefore, we decided that the Plan does not have to 
pay for testing services provided on December 19, 2022, billed with code 76706-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 20, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you have been underpaid for this claim. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 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 ambulance services have been met. 
Specifically, records of the ambulance services provided on November 20, 2022, have not been provided for 
review. Therefore, we decided that the Plan does not have to pay for ambulance services provided on 
November 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy telehealth services provided from 
August 9, 2022, to January 23, 2023. 
 
You asked the Plan to pay for the psychotherapy telehealth services. The Plan denied your request. The Plan 
says out-of-network virtual care is not covered. 
 
The Plan contract does not cover out-of-network virtual care. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover out-of-network virtual 
care. Based on this information, we decided that the Plans rules for coverage of the psychotherapy telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy 
telehealth services provided from August 9, 2022, to January 23, 2023.
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 
June 27, 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 June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that the CGM and supplies are 
medically necessary for you to control your diabetes. The Plan denied your request. The Plan says a CGM and 
supplies are 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 therapeutic CGM and supplies. Our 
reviewer says that criteria has not been met. Our physician reviewer found criteria for coverage include low 
blood sugars or insulin use in order to meet coverage criteria for CGM coverage. The documentation shows 
you do not take insulin and appears you are only on metformin for your diabetes mellitus. Therefore, coverage 
criteria are 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 a therapeutic CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic CGM and supplies.
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). 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that the enrollee is eligible to receive 
the product under Medicare guidelines. The Plan denied your request. The Plan says the Medicare criteria was 
not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the supply allowance for a CGM. Our 
reviewer says that the coverage criteria for the CGM are not met. Our physician reviewer found that coverage 
criteria for CGM requires low blood glucose sugar levels or insulin use; we are not told of low blood glucose 
sugar levels and the enrollee is not taking insulin. Hence the coverage criteria are not met at this time. Although 
the CGM may indeed help the enrollee improve blood glucose control the criteria was 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 supply allowance for a CGM have not been met. Therefore, we decided that 
the Plan does not have to pay for the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ambulance service provided on 
January 07, 2023. 
 
You asked the Plan to waive the coinsurance for the ambulance service. You say that you were admitted as an 
inpatient and should have the ambulance coinsurance waived. 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 30% 
coinsurance for ambulance services. 
 
You have been asked to pay 30% coinsurance for the ambulance service. 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. The Plan contract says that only in-network ambulance copayments can be waived, not out-of-
network coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
ambulance service provided on January 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 18, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you should not be responsible for the denied 
amount of $35.00. The Plan denied your request. The Plan says an eye refraction is never covered by Medicare. 
 
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 medical eye exam with 
diagnostic services. This does not appear to have been a routine exam. Based on this information, we decided 
that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye refraction (92015) provided on January 18, 2023.