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

 
We decided that the Plan has to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve the Dexcom G6 transmitter.. You say that the enrollee has post-bariatric 
surgery hypoglycemia and is not insulin-treated. The Plan denied your request. The Plan says that the enrollee 
does not meet criteria for the CGM. 
 
The Plan must follow 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 Dexcom G6 transmitter. Our 
reviewer says that the Dexcom G6 transmitter is medically necessary. Our physician reviewer found the 
enrollee has been having hypoglycemia although not diagnosed with diabetes mellitus and is not taking insulin. 
It is reasonable to approve the CGM in this case as post bariatric hypoglycemia can lead to severe low blood 
glucose sugar and this enrollee has used a method of preventing low blood glucose sugar that is well described 
and has used this successfully. 
 
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 Dexcom G6 transmitter. have been met. Therefore, we decided that the Plan 
has to pre-approve a Dexcom G6 transmitter.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
performed at an outpatient hospital provided on March 27, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital. You say that your copayment should be $180. 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 $295 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $295 copayment for a computed tomography (CT) scan performed at an 
outpatient hospital. This item/service falls within the outpatient diagnostic test 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 waive the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist visit provided on February 
07, 2023. 
 
You asked the Plan to waive the copayment for each specialist visit. You say that you disagree with the 
copayment assessed. 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 $30 
copayment for physician/practitioner services. 
 
You have been asked to pay a $30 copayment for each specialist visit. This item/service falls within the physician/practitioner 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. Therefore, we decided that the Plan does not have to waive the copayment for 
each specialist visit provided on February 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J0604-AX provided from November 2, 2022, 
to November 30, 2022. 
 
You asked the Plan to pay for procedure code J0604-AX. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes and modifiers. In this case, this claim cannot be paid as billed due to the inappropriate use of the AX modifier. Therefore, we decided that the Plan does not 
have to pay for procedure code J0604-AX provided from November 2, 2022, to November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a CT scan and Medicare Part B drugs provided on 
April 3, 2023. 
 
You asked the Plan to waive the cost for a CT scan and Medicare Part B drugs. You say that you were not 
aware the cost would be so high for the services rendered. 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 $600 deductible which applies to advanced imaging services. Your 
contract also says you must pay 10% coinsurance for Medicare Part B covered drugs and a $200 copayment for 
advanced imaging services. 
 
You have been asked to pay $823.08 for a CT scan and Medicare Part B drugs. This total includes a $600 
deductible, a $200 copayment for a CT scan, and $23.08 coinsurance ($230.84 allowed x 10% = $23.08) for 
Medicare Part B radiology drugs. The CT scan you asked the Plan to waive the cost for falls within the 
outpatient diagnostic tests benefit category. The Medicare Part B radiology drugs fall within the Medicare Part 
B prescription drugs category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $600 deductible which applies to advanced imaging services and Medicare Part B covered drugs. This 
cost sharing is a contractual obligation that had not been met at the time a CT scan and Medicare Part B drugs 
were received on April 3, 2023. Therefore, we decided that the Plan does not have to waive the cost for a CT 
scan and Medicare Part B drugs provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment and care planning service provided on February 
03, 2023. 
 
You asked the Plan to pay for assessment and care planning service. You say that it is the responsibility of the 
facility to obtain prior authorization. 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 assessment and care 
planning service provided on February 03, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for code 99222 billed for date of service February 11, 2023. 
 
You asked the Plan to pay for code 99222. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that you should have billed an observation care code 
(99218-99220) instead of code 99222 because the patient was not an inpatient on the date of service. 
 
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 99222 is Initial hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and moderate level of medical 
decision making. 
 
We find that CPT code 99222 is supported in the medical record. Specifically, the Plan's argument no longer 
applies.  Effective January 1, 2023, inpatient and observation care codes were combined and are billed the 
same.  This is reflected in the above-referenced description of code 99222.  Codes specific to observation care 
(i.e., codes 99218-99220) are no longer recognized. The services in dispute occurred after this change. Based 
on this information, we decided that Medicare rules for coverage of code 99222 have been met. Therefore, we 
decided that the Plan has to pay for code 99222 billed for date of service February 11, 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 a periodic oral evaluation and cleaning (D0120, D1110) 
provided on April 3, 2023, by an out-of-network (OON) provider. 
 
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 prior authorization was not obtained. Services could have been provided in-network. 
 
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 without prior authorization. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation and cleaning (D0120, D1110) provided on April 3, 2023, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 8, 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 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 April 05, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 
8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you couldn't find a dentist to help you. 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 dental services provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance services (D4910) provided on May 
4, 2023, to May 8, 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 periodontal maintenance services (D4910) provided on May 4, 2023, to May 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on November 3, 2022. 
 
You asked the Plan to pay for  ambulance response and treatment with no transport. You say that due to your 
pale coloring, shortness of breath, back pain and cold and clammy appearance along with sweating the store 
manager called the ambulance. You also say that the services should be covered. The Plan denied your request. 
The Plan says these services are not a covered benefit.  
 
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 November 3, 2022. 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 ambulance response and treatment with no 
transport provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
February 16, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you feel you should 
not owe the copayment when you were not given satisfactory service 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 $40 
copayment for a medical eye examination.  
 
 
  You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
medical eye examination 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 waive the copayment for a medical 
eye examination provided on February 16, 2023.  
 
Your complaint about the potentially unsatisfactory service 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on February 08, 2023, to March 09, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were not 
aware you had a copayment. 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 $20 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 total you owe is $120 ($20 per visit x 6 visits = $120). Therefore, we 
decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided on 
February 08, 2023, to March 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on February 17, 
2023. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you should not have an out-of-
pocket cost. 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 20% 
coinsurance for diabetes self-management training, diabetic services and supplies. 
 
You have been asked to pay 20% coinsurance for diabetic supplies. This item/service falls within the diabetes 
self-management training, diabetic services and supplies 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 total you owe is $44.51 ($222.54 allowed amount x 20% 
= $44.51). Therefore, we decided that the Plan does not have to waive the coinsurance for diabetic supplies 
provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gas permeable contact lenses (V2531) provided on 
November 23, 2021. 
 
You asked the Plan to pay for gas permeable contact lenses (V2531). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says they have paid the maximum allowed by your 
plan of benefits for this service. 
 
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 up to $180 every year for non-Medicare covered eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan pays up to $180 every year for non-
Medicare covered eyewear. The record shows this benefit has been exhausted with this service. Based on this 
information, we decided that the Plan's rules for coverage of gas permeable contact lenses (V2531) have not 
been met. Therefore, we decided that the Plan does not have to pay for gas permeable contact lenses (V2531) 
provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 5, 2023. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you did not realize you had a panoramic x-ray 
within the last 36 months, as you changed dentists and your benefits changed for 2023. 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 January 21, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 5, 
2023.