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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader and supplies. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 reader and supplies. You say that the enrollee is 
prediabetic with family history of being diabetic and is on a high dose of prednisone. You also say that the 
enrollee is elderly, living alone, legally blind and has various health issues such as severe arthritis fibromyalgia, 
depression, torn rotator cuff in her shoulder and trembling hands. The Plan denied your request. The Plan says 
based on a review of the information received, the enrollee does not meet the criteria for coverage. 
 
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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the Freestyle Libre 2 reader and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 2 reader and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 12, 2023. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were unaware that the coverage for the x-
rays was only once every two years. You also say that you advised the dentist to only do what was covered. 
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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has chronic low back pain 
due to degenerative disc disease that has resulted in the developments of vertebrogenic pain identified by 
degenerative endplates changes frequently know by the eponym modic on their magnetic resonance imaging 
(MRI). The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. 
 
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 pre-approve the Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found that there are 
multiple plausible pathologic sources of significant pain generation. The documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Also, the documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary or 
reasonable 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit for the evaluation and 
management of a new patient (99345) and advance care planning (99497) provided on September 12, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health service. You say that you were informed by Plan representatives 
on August 31, 2023, that no authorization was needed. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered.  
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 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 the home or residence visit for the evaluation and 
management of a new patient (99345) and advance care planning (99497) provided on September 12, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit provided on September 18, 
2023. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that you were not aware the service 
was out-of-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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 47% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 47% coinsurance for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 amount you owe is $102.94, which is 
47% coinsurance of the allowed amount for each item. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the office visit provided on September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency-department visit on March 
30, 2023, and outpatient specialist-physician services provided from June 2, 2023, to August 18, 2023. 
 
You asked the Plan to waive the copayment for an emergency-department visit and outpatient specialist-
physician services. You say that the charges at issue represent a financial hardship for you. 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 $95 
copayment for emergency care, a $250 copayment for each Medicare-covered computed tomography (CT) scan 
performed by a provider other than your primary-care physician, and a $40 copayment Medicare-covered 
physician specialist services.  
 
You have been asked to pay a $95 copayment for an emergency-department visit on March 30, 2023. This 
item/service falls within the emergency care benefit category. You have also been asked to pay a $40 
copayment each for outpatient specialist-physician services on June 9, 2023, June 23, 2023, July 7, 2023, July 
14, 2023, July 28, 2023, August 4, 2023, August 11, 2023, and August 18, 2023. These items/services fall 
within the physician/practitioner services benefit category. Finally, you have been asked to pay a $101.44 
copayment for a CT scan provided on June 2, 2023. This item/service falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay less than or 
equal to the full and 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 an emergency-department visit on March 30, 2023, and outpatient specialist-
physician services provided from June 2, 2023, to August 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on May 3, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you want to appeal the amount 
being charged. 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 $115 
copayment for other Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). The provider 
billed in the amount of $595 and the allowed amount is $93.65. This is less than the copayment amount. A 
payment was made in the amount of $30. For the service it's $93.65 - $30 = $63.65. Therefore, results in the 
total cost sharing amount of $63.65. 
 
You have been asked to pay a $63.65 cost share for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic shoes (A5500, A5514) provided on January 6, 2023. 
 
You asked the Plan to pay for the diabetic shoes. You say that these items were medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The clinical records do not document the need for this item. There is no order for the diabetic shoes. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for diabetic shoes (A5500, A5514) provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged office visit provided on April 5, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that authorization and primary care provider 
(PCP) name were added to the corrected claim. You also say that there are medical records to support the 
medical necessity of the claim. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the prolonged office visit provided on April 5, 2023, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service September 
18, 2023. 
 
You asked the Plan to pay for procedure code A4557. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4557 is considered bundled and 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 procedure code. 
 
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses provided on August 10, 2023. 
 
You asked the Plan to pay for progressive lenses. The Plan denied your request. The Plan says progressive 
lenses are not a covered vision benefit. 
 Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery 
with insertion of an IOL. 
 
We looked at the file and the Medicare rules. Medicare covers one pair of conventional eyeglasses or contact 
lenses furnished after each cataract surgery with insertion of an IOL. Therefore, we decided that the Plan does 
not have to pay for progressive lenses provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) for items purchased August 9, 2023. 
 
You asked the Plan to pay for sales tax. You say that please reconsider this claim The Plan denied your request. 
The Plan says sales tax is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
(S9999) for items purchased August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for co-surgeon services rendered on July 21, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation did not support the need for two or more surgeons. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support billing of co-surgeons. This was clearly a complex procedure 
and having a second attending assist is a very reasonable plan. However, the participation of the second 
surgeon cannot be billed as a co-surgeon or second lead surgeon. The second surgeon could only be counted as an assistant. Often this is not separately billable if a resident is available and scrubbed on the case. However, if 
there was documentation that there was no resident of suitable experience available, could consider 
resubmitting with a billing for surgical assistant with the appropriate documentation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for co-surgeon services rendered on July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on September 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 21, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on August 2, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and related services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are 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 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 the office visit and related services provided on 
August 2, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 28, 2023, 
through July 29, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was admitted for a left proximal ureteral stone w/hydronephrosis and a 
Urology consultation with possible stenting. The enrollee was then discharged home on July 29, 2023. The 
review has determined that the record did not show that at the time of the inpatient admission it was reasonable 
for the admitting physician to expect that the enrollee's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollee's history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 28, 2023, through July 29, 2023.