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

 
We decided that the Plan does not have to waive the coinsurance for the high strength lightweight wheelchair 
provided from March 19, 2020 through July 19, 2020. 
 
You asked the Plan to waive the coinsurance for the high strength lightweight wheelchair. You say that you did 
not agree to these payments. The Plan denied your request. The Plan says that there is a 20% coinsurance for 
durable medical equipment. 
 
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% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the high strength lightweight wheelchair. The high strength 
lightweight wheelchair falls within the Durable medical equipment (DME) and related 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 coinsurance for the high strength lightweight wheelchair 
provided from March 19, 2020 through July 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on June 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that medically necessary services were rendered. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-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 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 has network providers 
available who can provide 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 outpatient services provided on June 1, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services rendered from June 
2, 2020 to June 17, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that the services should be covered. 
The Plan denied your request. The Plan says the copayments were applied 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 per provider per day for all other laboratory testing other than HbA1C testing.  
 
Review of the file shows that you received laboratory services on June 2, 2020. Per the contract with the Plan, 
there is a $20 copayment per provider per day for all other laboratory testing other than HbA1C testing. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the 
Medicare allowed amount for these services was $18.33. Given that the allowed amount was less than the $20 
copayment, you have been asked to pay $18.33 for these services. 
 
The file shows that you received laboratory services on June 3, 2020. Per the contract with the Plan, there is a 
$20 copayment per provider per day for all other laboratory testing other than HbA1C testing. This cost sharing 
is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed 
amount for these services was $14.38. Given that the allowed amount was less than the $20 copayment, you 
have been asked to pay $14.38 for these services. 
 
The file shows that you received laboratory services on June 17, 2020. You have been asked to pay a $20 
copayment for these services. These services fall within the all other laboratory testing other than HbA1C 
testing, benefit category. This means that you have been asked to pay the correct amount based on the 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 copayments for the laboratory services rendered 
from June 2, 2020 to June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on January 8, 2020. 
 
You asked the Plan to pay for dental services. You say that the dentist practices general dentistry. You say that 
the dentist advised you are having problems chewing because your jaw is eroded. The Plan denied your 
request. The Plan says complete dentures are only covered once every five years and the remaining services are 
not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided June 24, 2020. 
 
You asked the Plan to pay for the total electric hospital bed. You say that the bed was medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
(E0265) provided June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 4, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on November 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
January 31, 2020. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's treatment 
was not hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible 
for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on July 19, 2019. 
 
You asked the Plan to pay for the ophthalmology services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 did not pre-approve the 
services 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 ophthalmology services provided on July 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 9, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial office visit (99202) and laser therapy (S8948) 
provided September 5, 2019 to October 9, 2019. 
 
You asked the Plan to pay for the office visit and laser therapy. You say that you thought the spinal 
manipulations would be covered in full and possibly the laser therapy. The Plan denied your request. The Plan 
says these services are not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the initial office visit (99202) and laser therapy (S8948) provided September 
5, 2019 to October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on February 5, 2020. 
 
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 procedure codes J3490, J0735, and J2270 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. The definition of code J0735 
is injection, morphine sulfate, up to 10 mg. The definition of code J2270 is injection, clonidine hydrochloride, 
1 mg. 
 
We find that CPT codes J3490, J0735, and J2270 are not supported in the medical record. Specifically, the 
documentation indicates that morphine, bupivacaine, fentanyl, and clonidine were mixed/compounded and 
there is a more appropriate code for these services instead of the three billed codes. 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 injection services rendered on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on April 26, 2020. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator rendered on April 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external electrocardiographic 
monitoring services (93226) provided April 22, 2020. 
 
You asked the Plan to waive the copayment for the external electrocardiographic monitoring services. You say 
that you would like to clarify the amount of copays for the monitor as you are aware virtual visits do not have a 
copay. The Plan denied your request. The Plan says this claim was processed and the correct copayment 
applied per the Evidence of Coverage. 
 
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 $15 
copay for specialist office visits.  
 
You have been asked to pay $15 copay for the electrocardiographic monitoring services. The 
electrocardiographic monitoring services 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 the external 
electrocardiographic monitoring services (93226) provided April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided to the enrollee on 
April 8, 2020. 
 
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The proof of delivery for these items does not have the 
same ship date as the billed date provided for these items. 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 the durable medical equipment provided to the enrollee on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 27, 2020. 
 
You asked the Plan to pay for the wound care. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
wound care services. 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 wound care provided on May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on May 
27, 2020. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that you were told you did 
not have to pay this amount and not to worry about it. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. The Plan also says that they have reduced your copayment 
amount from $100 to $50. 
 
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 $50 
copayment for in-network diagnostic mammogram at an outpatient hospital.  
 
You have been asked to pay $50 copayment for diagnostic mammogram. Diagnostic mammogram 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 a diagnostic mammogram provided on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 1, 
2020. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was provided following an unsolicited outreach call. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator 
(E0745) provided on May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear you received on May 22, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the request exceeds the 
benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 per year. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid $100 toward the eyewear. You 
are responsible to pay the difference for any amount over the $100 benefit limit. Based on this information, we 
decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay for the eyewear you received on May 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4Kscore testing. 
 
You asked the Plan to pre-approve 4Kscore testing. You say that you previously had a negative biopsy and an 
elevated PSA. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because your Prostate Specific Antigen (PSA) is 10.68 ng/ml but it should be greater than 3 and less 
than 10 ng/ml for patients age 45 years or older. 
 
The Plan follows Medicare rules. Medicare rules say that 4Kscore testing is only covered when the clinical 
criteria described above have been met.  
 
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 4Kscore testing. Our reviewer says that 
you do not meet the Medicare criteria for this testing. Our physician reviewer found your Prostate Specific 
Antigen (PSA) is not less than 10 ng/ml. This testing is not medically reasonable and necessary because the 
utility of the 4Kscore test has not been scientifically determined to improve subsequent health-related outcomes 
such as mortality, morbidity, or quality of life. The 4Kscore test has not been shown to reduce the number of 
prostate biopsies in clinical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4Kscore testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary catheters (A4351) provided from March 20, 2019, to 
June 18, 2019. 
 
You asked the Plan to pay for urinary catheters. You say that this should be covered. The Plan denied your 
request. The Plan says a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The physician order 
included in the file designates a different supply code than the billed code. 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 urinary catheters (A4351) provided from March 20, 2019, to June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on November 28, 2019. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on November 28, 2019.