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

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (PWC) with 
multiple power options (K0861) and related accessories. 
 
You asked the Plan to pre-approve a group 3 PWC with multiple power options and accessories. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items are medically 
necessary. 
 =The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple power options is 
covered when the criteria listed in the Medicare Rules section is met. Related accessories are denied as not 
medically necessary if the base wheelchair is denied. 
 
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 group 3 PWC with multiple power 
options and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the enrollee has adequate upper body capacity to manage standard power drive controls, she does not 
have high risk for skin breakdown, or uses a catheter or have spasticity. 
 
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 group 3 PWC with multiple power options and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair 
(PWC) with multiple power options (K0861) and related accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this is a crossover claim and the 
admit date cannot be changed to match the Notice of Admission date. The Plan denied your request. The Plan 
says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73600 billed for date of service December 
19, 2022. 
 You asked the Plan to pay for procedure code 73600. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 73600 is bundled into 
payment for code 73610. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73600 
is a column II code to column I code 73610. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73600 billed for date of service December 19, 
2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the drug administration provided on January 26, 
2023. We also decided that the Plan does not have to fully waive the coinsurance for the drug administration 
provided on January 26, 2023.  
 
You asked the Plan to waive the coinsurance for the drug administration. You say that you were told this would 
be fully covered. The Plan denied your request. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to reduce the coinsurance for the drug administration.  
 
The Plan contract says that enrollees cannot be asked to pay more than 20% coinsurance for drug 
administration. Therefore, we decided that the Plan has to reduce the coinsurance for the drug administration 
provided on January 26, 2023.  
 
We also decided that the Plan does not have to fully waive the coinsurance for the drug administration. 
 
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 20% 
coinsurance for the drug administration.  
 
You are responsible for 20% coinsurance of the allowed amount for Part B drugs and administration. This 
item/service falls within the Medicare Part B drugs benefit category. This cost sharing is a contractual 
obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
fully waive the coinsurance for the drug administration provided on January 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on January 19, 2023. 
 
You asked the Plan to pay for dental services. You say that you believe this service should be covered by your 
insurance. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) is not covered 
under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9310 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a deep axillary node biopsy (38525) billed on August 26, 
2022. 
 
You asked the Plan to pay for a deep axillary node biopsy. You say that this is supported in the records. The 
Plan denied your request. The Plan says this is not the most appropriate code for the service performed. 
 
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 38525 is biopsy or excision of lymph node(s); open, deep 
axillary node(s). 
 
We asked our coder 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 a deep axillary node biopsy. Our reviewer says that the billed 
code is not supported. Our reviewer found the performed excision was from the subcutaneous tissue only. There is a more specific code to report this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a deep axillary node biopsy have not been met. Therefore, we decided that the 
Plan does not have to pay for a deep axillary node biopsy (38525) billed on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on September 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should not have to pay the balance 
from the services received. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on September 16, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of treatment. The 
Plan denied your request. The Plan says the code is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. Use of local anesthesia is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code J3490 billed for date of service January 27, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stem cell therapy treatment and procedure to remove a 
blood clot to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve stem cell therapy treatment and procedure to remove a blood clot. You say 
that you have a blood clot and are on a blood thinner. You also say that you cannot walk a block without pain. 
The Plan denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
stem cell therapy treatment and procedure to remove a blood clot to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 15, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service has been 
reimbursed in the past. You also say you do not understand why this was denied. The Plan denied your request. 
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be 
made to a provider that has opted out of Medicare. 
 
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 the office 
visit provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 22, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that this service was not authorized. 
 
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 Plan contract also says that the enrollees POS benefit does 
not apply to an out-of-network office visit. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 an office visit provided on August 22, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chiropractic services provided on 
October 26, 2022. 
 
You asked the Plan to waive the deductible for the chiropractic services. You say that this provider is in-
network. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network chiropractic 
services. Your contract with the Plan also says that you must pay 8% coinsurance after meeting the deductible 
for out-of-network chiropractic services. 
 
The item or service you asked the Plan to waive the deductible for falls within the chiropractic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to out-of-network chiropractic services. This cost sharing is a contractual obligation 
that had not been met at the time the chiropractic services were received on October 26, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for the chiropractic services provided on October 
26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing billed for date of service December 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the unique identifier was not billed as required. 
 
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. A review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing billed for date of 
service December 22, 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 provided from September 30, 2021, 
to October 29, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services 
were not billed as required. 
 
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. In this case, there are insufficient medical records for the dates of 
service at issue to support the billed charges. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from September 30, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) x5. 
 
You asked the Plan to pre-approve dental services. You say that you need the request approved because you do 
not have many teeth and you cannot eat. The Plan denied your request. The Plan says these services are not 
covered under your Plan. 
  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. Complete denture - maxillary 
(D5110) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110 and D7210 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete denture - maxillary (D5110) and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor kit. You say that the enrollee is an insulin 
dependent diabetic that requires frequent testing and adjustment of insulin dosages. You also say that this meter 
will prevent numerous painful daily finger-sticks. 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 Freestyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that this provider was the only one available to 
render the services via tele-video. You say that the enrollee is homebound due to Covid19. You also say that 
the enrollee did not have the option to go to a network provider. The Plan denied your request. The Plan says 
payment cannot be made for services rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 office visit provided on September 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered because the enrollee is not on insulin. 
   
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 a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 10, 2022 to 
March 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the admission date is October 13, 
2021 and cannot be changed to match the Notice of Admission date. The Plan denied your request. The Plan 
says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 10, 2022 to 
March 11, 2022.