Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for remote electrocardiogram (EKG) testing provided on September 10, 
2019. 
 
You asked the Plan to pay for remote EKG. You say that you are appealing with records. The Plan denied your 
request. The Plan says that the denial of payment for this testing is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 remote EKG. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has well documented cardiac rhythm disorders. This testing was medically 
indicated based on the history of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of remote EKG have been met. Therefore, we decided that the Plan has to pay for 
remote electrocardiogram (EKG) testing provided on September 10, 2019.  
 
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 the assisted listening devices you received on March 12, 
2020. 
 
You asked the Plan to pay for the assisted listening devices. You say that you were told this would be covered. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 the Plan pays up to a 
$700 benefit allowance per hearing aid, every 3 years.  
 
Review of the file shows that you were provided assisted listening devices on March 12, 2020. The Plans 
supplemental benefit only covers hearing aids. Assisted listening devices are not covered under this benefit. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay for the assisted listening devices you received on 
March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray 
provided on February 18, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you were 
informed the office accepted Medicare patients. You say that you haven't received a refund yet. The Plan 
denied your request. The Plan says payment cannot be issued for services performed by 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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation and panoramic x-ray provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering services provided on March 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 3D rendering services are covered when the above 
criteria are 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 pay for the services. Our reviewer says that the 
requested 3D rendering services are not medically reasonable and necessary. Our physician reviewer found that 
this case of generalized abdominal pain only requires a standard CT without contrast as an initial test. There 
was no clinical indication noted to justify 3D rendering in the provided 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 the 3D rendering services provided on March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), arthrocentesis (20611), and the 
methylprednisolone acetate injection (J1030) rendered by the out of network (OON) provider on February 10, 
2020. 
 
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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the office visit (99213), arthrocentesis (20611), and the methylprednisolone acetate 
injection (J1030) rendered by the out of network (OON) provider on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on March 25, 2020. 
 
You asked the Plan to pay for medical supplies. You say that the provider is ineligible from billing Medicare. 
The Plan denied your request. The Plan says the denial of payment for these items is correct, because no 
payment can be made for items provided by this government entity provider. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for items and services 
furnished by a provider of service or agency of the Federal government, such as the United States Department 
of Veterans Affairs (VA).  
 
We looked at the file and Medicare rules. These items were furnished by a provider of the VA, and are 
therefore not payable by Medicare. Based on this information, we decided that Medicare rules for coverage of 
medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical 
supplies provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on March 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on March 4, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you require the stockings and you 
cannot afford them. The Plan denied your request. The Plan says compression stockings are non-covered as 
they do not meet the definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat 
exchanger services coded 99190 provided on March 10, 2020. 
 
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are 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. 
 
In this case, the CPT Code Manual definition of code 99190 is assembly and operation of pump with 
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. 
 
We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided 
while the enrollee was inpatient in the hospital. Payment for these services are included in the Part A DRG 
payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly 
and operation of pump with oxygenator or heat exchanger have not been met. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services 
coded 99190 provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on October 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on October 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the eye refraction provided on May 5, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says that the services received are not a covered benefit. 
 
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 when [Insert why/when the plan covers routine vision]. 
 
We looked at the file and the Plan's rules. Review of the file shows that you received an eye exam and eye 
refraction on May 5, 2020. The eye exam and eye refraction were provided by an in network provider. The EOC states that eye refractions during a routine exam performed by an in network provider. 
In-Network Providers are covered. The plan states that the eye refraction is not covered due to being during a 
medical vision check. The documentation does not support that the eye refraction was not provided during a 
routine exam. In addition, Medicare rules say that a contract provider is an agent of the plan. Services and 
referrals given by a contract provider are considered approved by the plan unless notice is provided that the 
services will not be covered. The services received were provided by a network provider. The file does not 
show that the Plan provided notice that the eye refraction would not be covered. Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have been met. Therefore, we decided that the 
Plan has to pay for the eye refraction provided on May 5, 2020.  
 
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 the eyeglasses provided on May 21, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits. 
 
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 anything 
over $150 for eyeglasses.  
 
The plan covers $150 allowance for eyeglasses. Review of the file shows that the total price for your eyeglasses 
were $299. The plan covers $150 of this amount. You have been asked to pay the remaining $149 for the 
eyeglasses. The eyeglasses fall within the vision care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic shoes (A5507) provided February 18, 2020. 
 
You asked the Plan to pay for the diabetic shoes. You say that the shoes are a covered item and were medically 
necessary. The Plan denied your request. The Plan says the shoes are a covered benefit only when purchased 
from a Medicare participating provider. The retail store from which the shoes were purchased does not 
participate in 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 provider who has opted out of the program except in 
cases involving emergencies or urgently needed care. 
 
The items at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider does not participate in the Medicare program. Therefore, we decided that the Plan does not have to 
pay for diabetic shoes (A5507) provided February 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the correct claim of the telephone evaluation and management service 
provided on April 15, 2020. 
 
You asked the Plan to pay for the telephone evaluation and management service (99443). You say that your 
physician office was closed so you were asked to have a telephone conference with a contracted specialist. The 
Plan denied your request. The Plan says that the provider billed the claim incorrectly and they have informed 
them a corrected claim will need to be submitted. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the telephone evaluation and management service (99443) by a contract provider. The 
file does not show that the Plan provided notice that the telephone evaluation and management service (99443) 
would not be covered. Under Medicare rules, this means the telephone evaluation and management service 
(99443) is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the correct 
claim of the telephone evaluation and management service provided on April 15, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 18, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
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 March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on November 21, 
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 procedure code 99239 is 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 31 minutes of hospital discharge services spent on the enrollee. 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 hospital discharge services rendered on November 21, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
March 15, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER on March 13, 
2020 for a bloody nose.  During that visit, they packed your nose.  You then returned two days later to the ER 
to have the packing removed. You said that if you had known you would have had a second ER copayment, 
you would have removed the packing yourself. The Plan denied your request. The Plan says you were charged 
this copayment 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 $50 
copayment for per emergency room visit.  
 
You have been asked to pay a $50 copayment for the ER visit. This copayment applies regardless of the reason 
for your visit to the ER. 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 emergency room (ER) visit 
you had on March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99212) on 
November 30, 2018. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were under the 
impression you were receiving inpatient care on the date of service. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
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 $50 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
In this case, a representative of the provider confirmed that you were designated as an outpatient observation 
patient on November 30, 2018. You have been asked to pay $26.83 for a specialist office visit. A specialist 
office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. 
This means that you have been asked to pay less than the full 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 specialist office visit (99212) on November 
30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 31, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physicians 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 physician's services provided on January 31, 2020.