Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Inogen portable oxygen concentrator provided in the 
Argentine Republic on March 5, 2020. 
 
You asked the Plan to pay for portable oxygen concentrator. You say that the airline does not provide 
continuous oxygen during flights. The Plan denied your request. The Plan says the denial of payment for this 
item is correct, because items and services furnished outside of the United States are covered only for 
emergencies and portable oxygen to fly back to the United States would not be covered under those 
circumstances. The Plan also says that they have paid for the other services you requested reimbursement for, 
therefore this denial is only for the portable oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are excluded from coverage except in certain specific circumstances. The Plan has a 
supplemental worldwide coverage benefit that goes beyond Medicares coverage. For that reason, the Plans 
benefits apply. The Plan covers worldwide emergency and urgent care services. 
 
We looked at the file and Medicare rules. This portable oxygen concentrator was purchased for use on a 
commercial air flight. This is not one of the limited circumstances in which Medicare covers an item furnished 
outside of the United States. Furthermore, this was not emergency or urgent care and therefore is not covered 
by the Plans supplemental worldwide benefit. Based on this information, we decided that Medicare rules for 
coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have 
to pay for an Inogen portable oxygen concentrator provided in the Argentine Republic on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on May 20, 
2020. 
 
You asked the Plan to pay for the additional periapical x-ray. You say that all of the x-rays should have been 
paid. The Plan denied your request. The Plan says 1 periapical x-ray per calendar year is covered. The Plan also 
says the frequency limit has been exceeded. 
 
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 and periapical x-rays are covered, the 
frequency limit of 1 per calendar year has been exceeded. The record shows that the Plan paid for the initial 
periapical x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to 
pay for the additional periapical x-ray (D0230) provided on May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 24, 2019, to November 27, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly 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 $50 
copayment each day, for days 1-7 per admission, for Medicare-covered inpatient hospital care visits.  
 
You have been asked to pay $150 ($50 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from November 24, 
2019, to November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on December 4, 
2019. 
 
You asked the Plan to pay for this testing. You say that this testing should be covered. The Plan denied your 
request. The Plan says Medicare coverage criteria are not met. 
 
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 pay for this testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was a 90-year-old female with various medical conditions and medications being 
used. A request for gene testing was made and completed. There was no documentation found that suggested 
the testing was to correct an issue or treat a condition specifically, and so it appears that this testing was for 
screening purposes. Without a clear indication for this genetic testing or a plan for specifically how the results 
would change the treatment plan moving forward, there was insufficient justification for the test. Therefore, the 
pharmacogenetic testing will be considered not medically necessary, based on the provided records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing provided to the enrollee on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on October 4, 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 was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on October 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical and imaging services (21499, 76102, 77077, A4580) 
provided by the physician on April 29, 2020. 
 
You asked the Plan to pay for surgical and imaging services. You say that this was the only local provider who 
could treat your conditions. The Plan denied your request. The Plan says this provider has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
surgical and imaging services (21499, 76102, 77077, A4580) provided by the physician on April 
29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit, specialist office visits and 
lab work and coinsurance for an x-ray provided by participating and non-participating providers on January 22, 
2020 to March 13, 2020. 
 
You asked the Plan to waive the copayment for an office visit, specialist office visits and lab work and 
coinsurance for an x-ray. You say that you were told that these would be waived as long as these services were 
provided by in-network providers. The Plan denied your request. The Plan says the correct copayments and 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $25 copayment physician/practitioner services/out-of-network/office visits, a $35 copayment for 
physician/practitioner services/in-network/specialist, a 35% coinsurance for outpatient diagnostic tests/out-of-
network/x-rays and a $20 copayment for outpatient diagnostic tests/lab.  
 
The enrollee has been asked to pay a $25 copayment physician/practitioner services/out-of-network/office 
visits, a $35 copayment for physician/practitioner services/in-network/specialist, a 35% coinsurance of the 
 
 
allowed amount for outpatient diagnostic tests/out-of-network/x-rays and a $20 copayment for outpatient 
diagnostic tests/lab.  
 
Date of Service Allowed Amount Copayment Coinsurance Amount Being Asked To Pay 
January 22, 2020  $20  $20 
January 23, 2020  $35  $35 
January 23, 2020  $20  $18.35 
January 27, 2020  $20  $20 
January 27, 2020 $42.33  35% $14.81 ($42.33 x 35% = $14.81) 
January 29, 2020  $35  $35 
February 4, 2020  $35  $35 
February 7, 2020  $25  $25 
February 7, 2020  $20  $20 
February 7, 2020  $35  $35 
February 18, 2020  $20  $11.89 
February 27, 2020  $35  $35 
March 3, 2020  $25  $25 
March 3, 2020  $10  $10 
March 13, 2020  $20  $8.46 
 
Total amount you are being asked to pay is $286.81 which is less than your cost sharing amount of $288.51. 
 
An office visit falls within the physician/practitioner services/out-of-network/office visits benefit category, 
specialist office visits fall within the physician/practitioner services/in-network/specialist benefit category, an 
x-ray falls within outpatient diagnostic tests/x-rays benefit and lab work falls within outpatient diagnostic 
tests/lab 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 upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit, 
specialist office visits and lab work and coinsurance for an x-ray provided by participating and non-
participating providers on January 22, 2020 to March 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan you had at an outpatient 
hospital facility on May 20, 2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that this test was needed as part of a 
follow-up from your knee replacement.  You want to know why this service wasn't covered. The Plan denied 
your request. The Plan says because the allowed amount is less than your copayment responsibility, you were 
charged the full amount for this service. 
 
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 $250 
copayment for diagnostic procedures or tests at a network outpatient facility.  
 
You have been asked to pay a $250 copayment for the duplex scan. The duplex scan falls within the diagnostic 
procedures or tests at a network outpatient facility 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 the duplex scan you had at an outpatient hospital facility on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on May 31, 
2020. 
 
You asked the Plan to provide reimbursement for these eyeglasses. You say that you do not believe that the 
contract is clear enough for you to have known that you would not be able to use the $300 on two pairs of 
glasses. The Plan denied your request. The Plan says your contract only covers one pair of glasses every 12 
months. 
 
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 up to one pair of lenses/frames every 12 months up to a $300 allowance. 
 
We looked at the file and the Plan's rules. We find that the contract indicates in two places that the benefit is 
applicable only to one pair of eyeglasses and also that benefits must be used on a single date of service. Based 
on this information, we decided that the Plan's rules for coverage of these eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on 
May 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services for the enrollee from 
February 7, 2020, to March 7, 2020. 
 
You asked the Plan to pay for this service. You say that SNF services were medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 
pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found the records do not show the enrollee required daily skilled nursing or daily skilled therapy. The enrollee 
did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility services for the enrollee from February 7, 2020, to March 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for breast prosthesis mastectomy bra (L8000) silicone Breast 
prosthesis (L8030, LT) custom breast prosthesis (L8035, LT) provided December 27, 2019. 
 
You asked the Plan to pay for the prosthetics. You say that the provided records should support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the records do not support the service 
billed. 
 
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 shipping/billing invoice and proof of delivery for the supplies 
provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. The submitted invoice indicates 
the item was shipped on 12/16/2019, however, the billed date of service is 12/27/2019. 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 breast prosthesis mastectomy bra (L8000) silicone Breast prosthesis 
(L8030, LT) custom breast prosthesis (L8035, LT) provided December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (X-Ray) of chest (714046) and 
the setup of portable x-ray equipment (Q0092) provided on April 24, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for set up of portable X-Ray equipment and X-Ray of chest. You say that the 
services were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained for out-of-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 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 radiologic examination (X-Ray) of chest 
(714046) and the setup of portable x-ray equipment (Q0092) provided on April 24, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the baclofen injection services provided on April 6, 2020. 
 
You asked the Plan to pay for the baclofen injection 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 supported by the 
documentation. 
 
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 J0475 is not supported in the medical record. Specifically, the documentation submitted 
does not support the units billed (8 units). Based on this information, we decided that Medicare rules for 
coverage of the baclofen injection services have not been met. Therefore, we decided that the Plan does not 
have to pay for the baclofen injection services provided on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided to the enrollee from July 1, 2019, 
to July 31, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. The Plan denied the 60-day episode of care claim 
with reason, 1284 RAP required in order to process per the CMS guidelines. The Plan says that a search of the 
claims history shows no RAP claim in entered into the claim system. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered.  
 
The provider is a non-contract provider for the enrollee's health plan and a valid RAP claim was not submitted 
prior to the final claim for processing. Therefore, we decided that the Plan does not have to pay for home health 
care provided to the enrollee from July 1, 2019, to July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
19, 2020. 
 
You asked the Plan to pay for the dental service. You say that you are not happy with the cleaning services you 
received. The Plan denied your request. The Plan says comprehensive oral evaluations are covered once every 
3 plan years. The Plan also says the frequency limit has been exceeded. 
 
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 and comprehensive oral evaluations are 
a covered service, the frequency limit of 1 every 3 plan years has been exceeded. The record shows that the 
Plan previously paid for this service that you received on July 11, 2019. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis coded L1851, the addition to lower 
extremity coded L2385, and the addition to lower extremity orthosis coded L2397 provided on April 14, 2020. 
 
You asked the Plan to pay for the knee orthosis, the addition to lower extremity, and the addition to lower 
extremity orthosis. You say that you would like the plan to reconsider their denial The Plan denied your 
request. The Plan says there is missing required information. 
 
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. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service from the billing company. 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 knee orthosis coded L1851, the addition to lower extremity 
coded L2385, and the addition to lower extremity orthosis coded L2397 provided on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canals (D3310 x 2) and the additional periapical x-
rays (D0230 x 2) provided on April 27, 2020 by the out of network dentist. 
 
You asked the Plan to pay for the root canals and the 2 additional periapical x-rays. You say that you were 
never advised that the services you received would not be covered. You also say that the provider's office is 
listed in the Dental Provider Directory. The Plan denied your request. The Plan says root canals are not listed as 
a covered service. The Plan says 1 periapical x-ray per calendar year is covered. The Plan also says the 
frequency limit has been exceeded. 
 
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, root canals are not among those 
covered under this benefit. Although periapical x-rays are listed as a covered service, coverage is limited to 1 
per calendar year. The record shows that 1 periapical x-ray for this date of service was paid for by the Plan, 
thus the frequency limit has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
root canals (D3310 x 2) and the additional periapical x-rays (D0230 x 2) provided on April 27, 2020 by the out 
of network dentist.