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

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on April 30, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that these supplies are 
medically necessary. 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 durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $193.97. The total amount you are being asked to pay is $38.80 ($193.97 x 20% = 
$38.80). Durable medical equipment falls within the durable medical equipment/in-network 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 durable medical equipment provided by a participating 
provider on April 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on April 30, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you didn't have any 
other option but the emergency room. The Plan denied your request. The Plan says the correct copayment has 
been applied to the services provided. 
 
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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for an emergency room visit. Since emergency room care was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit 
provided by a participating provider on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an eye-wear allowance for eyeglasses purchased. 
 
You asked the Plan to pay for an eye wear allowance. You say that the eye wear allowance is $125. The Plan 
denied your request. The Plan says they no longer cover eyeglasses in 2020. 
 
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 one routine eye exam every year. 
 
We looked at the file and the Plan's rules. Eye wear is not a Plan covered benefit in 2020.  Based on this 
 
 
information, we decided that the Plan does not have to pay an eye wear allowance for eyeglasses purchased.
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 July 16, 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 July 16, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from November 1, 
2019, to November 16, 2019. 
 
You asked the Plan to pay for the SNF services. You say that the claim was billed with the correct code. The 
Plan denied your request. The Plan says that the PDPM code used is not correct for the services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The documentation in the case file shows that the Plan used claims processing rules for home health services 
(Claims Processing Manual Chapter 10) in their ruling. The Plan has not made reasonable and diligent efforts 
to gather and forward to us information regarding their decision to deny your request. Therefore, we decided 
that the Plan has to pay for the skilled nursing facility (SNF) services provided from November 1, 2019, to 
November 16, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram rendered on January 
24, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment 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 $200 
copayment for Essential plan members for other outpatient diagnostic tests.  
 
Review of the file shows that the enrollee received an echocardiogram on January 24, 2020. The enrollee has 
been asked to pay a $200 copayment for these services. These services fall within the other outpatient 
diagnostic tests benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
echocardiogram rendered on January 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider from January 6, 2020, to March 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you do not have out-
of-network benefits. 
 
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 you by an out-of-network provider from 
January 6, 2020, to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist/oncologist. 
 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care can be received from a 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 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 
a referral to an out-of-network hematologist/oncologist.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there are multiple providers in network with the same specialty 
and within appropriate time and distance to member. 
 
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 
the home health services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a superion interspinous spacer. 
 
You asked the Plan to pre-approve the superion interspinous spacer. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says 
current medical literature indicates that this service is considered experimental and investigational as it is not 
identified as widely used and generally accepted for the proposed use. 
 
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 superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this device is experimental and more research is needed to show its safety 
and efficacy. 
 
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 superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertical bitewings (D0277), panoramic x-ray (D0330), 
and preventive procedure (D1999) provided on May 19, 2020. 
 
You asked the Plan to pay for the vertical bitewings, panoramic x-ray, and preventive procedure. You say that 
you had services done that should be covered under your benefit. The Plan denied your request. The Plan says 
these services are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
vertical bitewings (D0277), panoramic x-ray (D0330), and preventive procedure (D1999) provided on May 19, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (LSO). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is documentation of a physician order for the requested back 
brace. There is no documentation to support that you need this brace. The Plan requested this information from 
your provider on multiple occasions and did not receive a response. 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 a lumbar-sacral orthosis (LSO).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 21, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent, 
referred by a network provider or approved in advance. 
 
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 medical services provided on July 21, 2020 by 
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9338) provided on March 3, 2020, 
through March 24, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9338 has a status indicator of I 
and is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9338 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9338 has a status indicator of I. The means that CPT code S9338 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9338) 
provided on March 3, 2020, through March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 25, 2019. 
 
You asked the Plan to pay for the testing services. You say that the gene panel will establish specific mutations. 
The Plan denied your request. The Plan says the testing is not FDA approved, and 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 test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
June 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the implanted pump pain management 
infusion services (S9328) provided. 
 
You asked the Plan to waive the coinsurance for the implanted pump pain management infusion services. You 
say that you have never paid this coinsurance amount in your 14 years receiving this service. The Plan denied 
your request. The Plan says the coinsurance applied correctly in this case. 
 
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 outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a total cost share amount of $460 for the implanted pump pain management 
infusion services ($145 +$75 + $150 + $90). The service provided 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 coinsurance for 
the implanted pump pain management infusion services (S9328) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 you by an out-of-network provider on June 
20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on July 6, 2020. 
 
You asked the Plan to pay for the radiology services (71046-26). You say that multiple services were done on 
this date of service. The Plan denied your request. The Plan says the claim was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show that two interpretations were performed 
and the dates of service on the submitted Imaging Reports are different than the claim date of service. Based on 
this information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24-hour ambulatory blood pressure monitoring (ABPM) 
services. 
 
You asked the Plan to pre-approve the ABPM services. You say that it is felt that ABPM would be helpful to 
ensure that blood pressure treatment is working, and that overmedication is not occurring to cause hypotension. 
The Plan denied your request. The Plan says this is not covered for this condition. 
 
The Plan follows Medicare rules. Medicare rules say that ABPM is covered as noted above to assess for either 
"white coat" or masked hypertension.  
 
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 ABPM services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable and necessary. 
Our physician reviewer found based on the records, the patient has marked systolic hypertension on in-office 
BP readings and no documented home readings or discrepancies between in-office readings and home BP 
readings. In this circumstance, coverage criteria for 24-hour ambulatory BP monitoring are not met since there 
are no documented covered indications for the procedure. Specifically, there are no home BP readings to 
increase concern of either "white coat" or "masked" hypertension. 
 
 
 
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 ABPM services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 24-hour ambulatory blood pressure monitoring (ABPM) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional first intraoral periapical x-ray provided on July
10, 2020.
You asked the Plan to pay for the additional first intraoral periapical x-ray. You say that at the time of the
appointment the enrollee was advised that their insurance might pay for the service. The Plan denied your
request. The Plan says only one intraoral/periapical x-ray is covered per calendar year. The Plan also says that
payment for one intraoral x-ray has already been authorized for payment by the Plan.
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, intraoral x-rays are limited to one
procedure per calendar year. The record shows that the enrollee received two first intraoral periapical x-rays on
July 10, 2020, one of which was covered by the Plan, and the enrollee's intraoral x-rays benefit has been
exhausted. Therefore, we decided that the Plan does not have to pay for the additional first intraoral periapical
x-ray provided on July 10, 2020.