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

 
We decided that the Plan does not have to reimburse for the wig purchased from November 21, 2019 through 
December 4, 2019. 
 
You asked the Plan to reimburse for the wig. You say that it is not fair if the wig benefit is only for hair loss 
due to cancer. The Plan denied your request. The Plan says Alopecia is not a covered diagnosis for a wig. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does offer a supplemental benefit which would 
provide coverage for a wig only for members who experience hair loss due to treatment of cancer. Therefore, 
we decided that the Plan does not have to reimburse for the wig purchased from November 21, 2019 through 
December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on 
December 23, 2019. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was 
medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate 
the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare requires that services provided/ordered/certified be 
authenticated by the persons responsible for the care of the enrollee in accordance with Medicare policies.   
 
The medical records do not mention or support medical necessity for the orthosis. 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 shoulder-elbow-wrist-hand orthosis provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on October 25, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that you were dissatisfied with the network provider. 
The Plan denied your request. The Plan says that the hearing benefit is not covered if the services are not 
ordered through the designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only ordered directl
 
We looked at the file and the Plan's rules. The file indicates the hearing aids were not ordered . Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on 
October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on September 24, 
2019. 
 
You asked the Plan to waive the copayment for vision care. You say that you disagree with the charges because 
this was a routine eye exam. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $25 
copayment per visit to diagnose and treat diseases of the eye, and a $0 copayment for routine eye exams. 
 
The medical records show that you received vision care beyond a routine eye exam on September 24, 2019. 
Therefore, you are responsible to pay the $25 copayment.  
 
You have been asked to pay a $25 copayment for vision care. Vision care falls 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 waive the copayment for vision care provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on 
April 8, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 DME and related supplies.  
 
You received DME and related supplies on April 8, 2020. Therefore, you are responsible to pay your share of 
the cost-sharing charges. Please see the chart below.  
 
Date of Service Service Code Allowed Amount Amount You Owe 
4/8/2020 E2402 $750 $150 
4/8/2020 A6550, A7000 $93.24 $18.65 
 
The total amount you owe is: $168.65. 
 
You have been asked to pay the total coinsurance amount of $168.65 for DME and related supplies. DME and 
related supplies fall within the DME and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for DME and related supplies provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
January 27, 2020. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that the Plan told you that 
you could purchase a portable oxygen system. The Plan denied your request. The Plan says per Medicare 
guidelines payment is not made for purchases of oxygen and oxygen equipment. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep. Medicare rules say that only rented oxygen 
equipment is eligible for coverage.  
 
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. 
Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen 
concentrator purchased on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 12, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) and lumbar-sacral orthosis (L0648) 
provided April 21, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the medical records and doctor's order clearly 
demonstrate medical necessity for the devices prescribed. The Plan denied your request. The Plan says the 
billed supply codes cannot be verified. 
 
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 itemized delivery ticket and proof of delivery, or relevant medical records 
which support medical necessity for the supplies provided in this case. 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 knee orthosis (L1833) and lumbar-sacral orthosis (L0648) provided April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 20, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 skilled nursing services provided on December 20, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a PET scan provided to the enrollee on March 9, 2020.
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says that PET procedures performed to inform the initial treatment strategy of tumors must be reported with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for the scan. Our reviewer says that the services at issue in this case are medically reasonable and necessary. Our physician reviewer found the dictated report of the 3/9/20 PET/CT listed "Squamous cell carcinoma of the pharynx" as the indication for the scan. This is a specific diagnosis which qualifies as a valid indication for the scan per CMS guidelines and should be reimbursed. 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 scan have been met. Therefore, we decided that the Plan has to pay for a PET scan provided to the enrollee on March 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 2, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 10, 2019. 
 
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 
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 laboratory services provided on June 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on February 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you did not see the patient. You say that these samples 
were sent to your lab. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 lab work provided on February 11, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records provided show these services were 
previously paid for by the Plan. 
 
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 looked at the file and Medicare rules. The file shows that the Plan previously paid for CPT codes 88342 
and 88305 on a previous claim. The file does not show that the claim in dispute in this appeal was for separate 
services from the services the Plan already paid for. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on November 13, 2019 through 
November 21, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says nonparticipating providers must bill their 
claims with a valid Patient Driven Payment Model (PDPM) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Specifically, this claim has not been submitted with a valid 
Health Insurance Prospective Payment System code under the new PDPM. Therefore, we decided that the Plan 
does not have to pay for SNF services provided on November 13, 2019 through November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 5, 2020 and 
February 6, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 February 5, 2020 and February 
6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for immunotherapy injections (95117) received 
on May 11, 2020. 
 
You asked the Plan to waive the copayment for immunotherapy injections. You say that you should not have to 
pay any copayment for your allergy shots. 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $10.36 copayment for immunotherapy injections. Immunotherapy injections fall 
within the "Physician/Practitioner services, including doctors 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 immunotherapy injections (95117) received on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2751) provided on January 28, 2020. 
 
You asked the Plan to pay for the crown. You say that you previously had an extraction and were experiencing 
pain and discomfort after. You also say this dentist recommended a crown, which you accepted and would like 
it to be covered based on necessity. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental 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, 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 crown 
(D2751) provided on January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; 3 views (CPT Code 71047) 
provided to the enrollee on September 11, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the information provided is insufficient to verify services. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray have not been met. With the information we have, 
we cannot determine how the member came to the servicing provider or whether the services are medically 
necessary. Non-contracted providers are required to furnish necessary information to the health plan when 
requested. After three or more attempts to obtain information, none was received as of this date. Therefore, we 
decided that the Plan does not have to pay for radiologic examination, chest; 3 views (CPT Code 71047) 
provided to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 7, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on May 7, 2019.