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

We decided that the Plan does not have to pay for outpatient hospital services provided on June 10, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
because the right to recover for services provided by eligible beneficiaries is not extinguished by specific plan 
requirements. The Plan denied your request. The Plan says the claim was not billed in accordance with CMS 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510 on TOB 13X. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, this claim was not submitted with 
the appropriate revenue code. Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided on June 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 15, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 laboratory services provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filter holder and integrated filter (A7507), housing and 
integrated adhesive (A7508), and the skin barrier (A5120) provided on January 9, 2020. 
 
You asked the Plan to pay for this items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items are not covered as the documentation 
indicating proof of delivery was not provided. 
 
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 for the supplies provided in this case. Specifically, the 
Delivery Ticket did not specify a valid date delivered or contain evidence of delivery. 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 filter holder and integrated filter (A7507), housing and integrated 
adhesive (A7508), and the skin barrier (A5120) provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140), two periodontal scalings and root 
planings (D4341 x2), and gingival irrigations (D4921 x2) provided on August 19, 2020, and August 26, 2020. 
 
You asked the Plan to pay for the extractions, scalings and planings, and gingival irrigations. You say that you 
are on a fixed income, and cannot afford to pay for this bill. The Plan denied your request. The Plan says your 
maximum allowable of $1,500 was met during the processing of this claim. 
 
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 $1,500 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 August 26, 2020, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the extractions (D7140), two periodontal scalings and root 
planings (D4341 x2), and gingival irrigations (D4921 x2) provided on August 19, 2020, and August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant-at-surgery services providing during the 
treatment of a humerus fracture. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services were ordered by the 
in-network surgeon and should be paid at network rates. The Plan denied your request. The Plan says this type 
of provider cannot be paid by Medicare for surgical assistant services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant-at-surgery services 
providing during the treatment of a humerus fracture.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on January 13, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says HIPPS codes created are valid only on claim lines with revenue code 0023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the denied services are not supported in the medical record. Specifically, these services were not 
coded and reported correctly. HIPPS codes created are valid only on claim lines with revenue code 0023. 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 home health services provided to the enrollee on January 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy service provided on April 2, 2020. 
 
You asked the Plan to pay for home infusion therapy service. You say that the Plan is denying this code in 
error. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
code is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. The billed code is not payable by Medicare. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy service have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy service provided on April 
2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device (E0651, E0667) 
provided on July 27, 2020. 
 
You asked the Plan to pay for an intermittent limb compression device. You say that this is supported in the 
medical records. The Plan denied your request. The Plan says the records do not document that the enrollee had 
stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The submitted medical records do not document that the enrollee has lymphedema or chronic venous 
insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an 
intermittent limb compression device (E0651, E0667) provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on August 25, 2020. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says Original 
Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for procedures performed in the 
course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered 
even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on 
August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the radiation therapy rendered from 
February 11, 2020 to March 27, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you believed the services would 
have no copayment. 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 $60 
copayment for each in-network Medicare-covered radiation therapy service.  
 
Review of the file shows that you received radiation therapy for six dates of service from February 11, 2020 to 
March 27, 2020. You have been asked to pay a $60 copayment per date of service for these services, for a total 
of $360. These services fall within the in-network Medicare-covered radiation therapy service benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the radiation therapy rendered from February 11, 2020 to 
March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic leg with advanced foot and ankle feature. 
 
You asked the Plan to pre-approve the prosthetic leg. You say that the prosthetic is necessary. The Plan denied 
your request. The Plan says the records show that a new socket is needed, but they do not show why a 
replacement foot is needed. The Plan states your current foot is still under warranty and that is why the 
replacement prosthesis still denied. The Plan states a request for a socket and accessories can be reviewed if 
submitted. 
 
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 
prosthetic leg. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the request was denied on prior review as no 
documentation of the need for the requested K3 foot. Current foot under warranty (RUSH87) and is seven (7) 
months old. Now stated to be too stiff. Request for a new socket appears to be reasonable and necessary, but 
there is insufficient evidence to support need for complete prosthetic replacement, including a new foot. There 
is an order signed by the physician for a completely new prosthesis. Per Medicare rules, "A prescription is not 
considered to be part of the medical record." The review has determined that the items/services at issue in this 
case are not medically reasonable and necessary based on the LCD. 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 
prosthetic leg have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
prosthetic leg with advanced foot and ankle feature.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services (A0425, A0427, A0431 
and A0436) and inpatient hospital care provided on February 24, 2020, through March 2, 2020. 
 
You asked the Plan to waive the copayment for ambulance and inpatient hospital care. You say that the 
services should be covered. The Plan denied your request. The Plan says the cost share was 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 $350 
copay for each Medicare-covered one-way trip via ground or air ambulance for ambulance care and $325 per 
day for days one through six for inpatient hospital care.  
 
You have been asked to pay two $350 copayments for each Medicare-covered one-way trip via ground or air 
ambulance for ambulance and inpatient hospital care. This service falls within the ambulance care benefit 
category. You have also been asked to pay $1,950 for six days of inpatient hospital care ($325 x 6=$1,950). 
This service falls within the inpatient hospital 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 waive the 
copayment for ambulance services (A0425, A0427, A0431 and A0436) and inpatient hospital care provided on 
February 24, 2020, through March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan of the shoulder provided. 
 
You asked the Plan to pay for the CT scan of the shoulder. You say that this was medically necessary and 
should be paid. The Plan denied your request. The Plan says the enrollee suffered this injury when working for 
the United States Census Bureau. As such, this service is payable by the Workers' Compensation insurance. 
 
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 directed the 
provider to bill the primary payer. As the secondary insurer, the Plan cannot be held responsible for the CT 
scan of the shoulder until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the CT scan of the shoulder provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a Vertiflex Superion Interspinous 
device at L3-L4 and L4-L5. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion 
Interspinous device in the setting of low back pain has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
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 pre-approve the implantation of a Vertiflex Superion Interspinous device at L3-L4 and L4-L5.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve MRI. You say that you have a disc disorder and have an MRI completed 
once per year to see what is going on. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because the records do not show why you would need this imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that you do not 
meet the Medicare criteria for the requested MRI. Our physician reviewer found there is no documentation in 
the records provided to support the need for an MRI for this indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Magnetic Resonance Imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on September 4, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have never had to pay for this 
before. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $62.73. The total amount you are being asked to pay is $12.55 ($62.73 x 20% = $12.55), an injection 
falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider on September 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for bilateral breast ultrasound (76642) 
provided August 24, 2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you thought this would be 
covered. You did not know you would have a $100 copayment for the ultrasound. The Plan denied your 
request. The Plan says this claim was processed and the correct copayment was 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$352 per 
day for Medicare covered diagnostic radiology services ($100 for ultrasounds).  
 
You have been asked to pay $100 copayment for the breast ultrasound. The breast ultrasound 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 bilateral breast ultrasound (76642) provided August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 27, 
2020. 
 
You asked the Plan to pay for the x-ray services. 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, we have confirmed that code 71045 
for the x-ray services has a bundled relationship with code 74022 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on 
September 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a network gap does not exist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
shoulder surgery to be provided by an out of network (OON) provider.