Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 11, 
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 has not been processed.
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the services are part of the claim. As the secondary insurer, the Plan cannot be held 
responsible for these services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 11, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for HSCT treatment provided in Mexico from July 
21, 2019 to August 17, 2019. 
 
You asked the Plan to reimburse you for the HSCT treatment. The Plan denied your request. The Plan says any 
non-emergency care received outside of the United States and the U.S. Territories are not covered by Medicare 
and are not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must pay for emergency and 
urgently needed services. Medicare rules say that urgently needed services are those needed because of an 
unforeseen illness or condition and it is not reasonable to get the services from the plan. The contract with the 
Plan says that any non-emergency care received outside of the United States and the U.S. Territories are not 
covered by Medicare and are not covered under any condition 
 
We looked at the file the Plan?s rules and Medicare rules. The file shows that the HSCT treatment was not due 
to an emergency or an urgently needed service because of an unforeseen illness or condition. The contract with 
the Plan says that any non-emergency care received outside of the United States and the U.S. Territories are not 
covered by Medicare and are not covered under any condition 
Therefore, we decided that the Plan does not have to reimburse you for HSCT treatment provided in Mexico 
from July 21, 2019 to August 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pharmacogenomics testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the tests on this panel can be approved if the results are needed for treatment. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have long-standing depression, which has been more pronounced of late. While 
pharmacogenomic testing may be scientifically interesting, it is not necessary to refer the enrollee to a 
psychologist, change his medication dose or to try a different medication. The requested service is not 
medically necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pharmacogenomics testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on March 6, 
2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never been 
charged for these supplies in the past. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
prosthetic devices 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 
ostomy supplies you received on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastopexy. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that this procedure is needed to correct congenital defects. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
requested surgery is not medically reasonable or necessary. Our reviewer found the medical documentation 
does not note a history of congenital deformity that preceded her augmentation to suggest that she had had 
reconstructive surgery. Implant removal and capsulectomy would likely address her functional impairment. 
There is insufficient evidence that an additional mastopexy would address any functional impairment or 
reconstructive need.  The requesting surgeon does not document evidence of the need for reconstructive 
surgery to address her breast ptosis. Therefore, mastopexy would likely provide aesthetic improvement without 
addressing a functional impairment or a congenital deformity/developmental 
abnormality/trauma/infection/tumors/disease. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve mastopexy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is only covered for certain conditions. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has a diagnosis of COPD, although medical records do not include pulmonary function tests. BiPAP during 
sleep is the appropriate treatment. There is no evidence of BiPAP failure. Medicare does not cover a home 
ventilator when used as BiPAP, or in the treatment of OSA or obesity hypoventilation syndrome.  A home 
ventilator is not medically necessary. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a deep pressure compression vest for the enrollee. 
 
You asked the Plan to pre-approve the vest. You say that this meets all of the stipulations for DME. The Plan 
denied your request. The Plan says that this is not an appropriate type of DME. 
 
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 pre-approve the vest. Our reviewer says that the 
requested deep pressure compression vest is considered medically reasonable and necessary in this case. Our 
physician reviewer found the vest has been prescribed for anxiety. This vest has been beneficial in some for 
treatment of behavioral disorders and is reasonable to try. Certainly exploring all non-pharmaceutical angles 
are worthwhile. 
 
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 vest have been met. Therefore, we decided that the Plan has to pre-approve 
a deep pressure compression vest for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery (66982) provided on November 7, 2019. 
 
You asked the Plan to pay for the cataract surgery. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the units 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 66982 is 1. You billed 89 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the cataract surgery have not been met. 
Therefore, we decided that the Plan does not have to pay for cataract surgery (66982) provided on November 7, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour test strips. 
 
You asked the Plan to pre-approve the strips. You say that you have used these for about five years. The Plan 
denied your request. The Plan says you have not tried the plan alternatives yet. 
 
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 strips. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the plan provides suitable test strips. Unless there is some intolerance or inability to use the approved 
strips, there is no indication to use the Contour test strips. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Contour test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit provided 
April 9, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that please see attached for all medical 
records and supporting documents confirming medical necessity. The Plan denied your request. The Plan says 
there is no actual physical exam. All information was provided over the phone. No actual treatment records 
were provided to substantiate the enrollee's orally reported medical history and the enrollee is not in an eligible 
geographical area for telehealth services. 
 
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, electronic shock unit provided April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2330 x2) provided on 
March 3, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that this service was not for cosmetic 
reasons. You also say that this procedure was necessary. The Plan denied your request. The Plan says your 
annual benefit is exhausted. 
 
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, the Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on March 10, 2020 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the two resin-based composites (D2330 x2) provided on March 
3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not support the required four week trial of the non-segmented 
device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal actual findings on a physical exam portion of a physician, NP, or PA 
progress note that indicates evidence of these findings on the patient exam or that the enrollee has unique 
characteristics that would indicate the segmented pump over a standard pump. There is not a trial and failure of 
a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on April 15, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that 
with limited exceptions, the enrollee must use network providers to get medical care and services. The only 
exceptions are emergencies, urgently needed services when the Plan?s network is not available, out-of-area 
dialysis services and cases in which the Plan authorizes use of out-of-network providers. 
 
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 
physical therapy 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 physical therapy services provided on April 15, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on April 6, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you received the 
ambulance services due to COVID-19. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $245 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $245 for these 
services. 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 ambulance services (A0429) provided on 
April 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B-covered drugs you 
received at a stand-alone infusion center from January 3, 2020 through February 28, 2020. 
 
You asked the Plan to waive the coinsurance for the infusion drugs. You say that you would like to appeal this 
coinsurance but you did not provide an explanation as to why in your appeal request. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 Medicare Part B-covered drugs you receive in a physician's office, a pharmacy, or at a hospital 
facility.  
 
You have been asked to pay 20% coinsurance for the infusion drugs. The location where you received your 
drugs is a free-standing infusion center, which is considered a physician's office. 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 Medicare Part B-covered drugs you received at a stand-alone infusion center from 
January 3, 2020 through February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the orthopedic office visit you had on on 
May 12, 2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that this was a follow-up visit and 
you couldn't go sooner because of COVID-19. 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the specialist visit. This copayment applies regardless of the 
reason for any possible delay in having the office visit. 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 orthopedic office visit you had on on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on April 21, 
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 item was provided in connection to a telehealth visit that does not meet 
Medicare criteria. 
 
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 April 21, 2020.