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

 
We decided that the Plan does not have to pay for the excision of a benign lesion, up to 1.25 cm, (D7410) 
provided on October 1, 2020. 
 
You asked the Plan to pay for the dental service. You say that the lesion was on the inside of the mouth lip 
area. You say that the lesion was becoming larger and was affecting your eating and drinking. You say that you 
did not want it to become any larger. You also say that you believe that this should be a covered service. The 
Plan denied your request. The Plan says the excision of a benign lesion, up to 1.25 cm, is not listed as a covered 
service. 
 
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 
excision of a benign lesion, up to 1.25 cm, (D7410) provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888RH) provided 
October 13, 2020. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you do not agree with this 
denial. The Plan denied your request. The Plan says because you requested to go to a specific facility, the extra 
mileage is not covered. 
 
Medicare pays for ambulance services only to the nearest appropriate facility. The Plan follows the same rules. 
 
We looked at the file and Medicare rules. The file indicates that you specifically requested to go to hospital 
farther away than the hospital closest to you. The additional miles incurred for this transportation is not 
covered. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the non-covered 
ambulance mileage (A0888RH) provided October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CellCept. 
 
You asked the Plan to pre-approve CellCept. You say that this enrollee needs this prescription as soon as 
possible. You also say that the enrollee does not have a secondary insurance or a Part D prescription plan. The 
Plan denied your request. The Plan says this drug is a self-administered drug, and is not Part B covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve CellCept.  
 
Benefits for CellCept may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on 
September 14, 2020. 
 
You asked the Plan to pay for the provided items. You say that the enrollee was treated by the physician who 
provided medical notes, necessity letter, and written order. The Plan denied your request. The Plan says there 
was not a claim for the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that that a treating practitioner must have a face-to-
face encounter with a beneficiary within the six months prior to prescribing items that appear on the Required 
List. 
 
We find that the orthoses are not supported in the medical record. Specifically, the records do not indicate the 
treating practitioner had a face-to-face encounter with the enrollee in the last six months. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services on September 22, 2020. 
You asked the Plan to pay for the transportation services. You say that the denial of the claim was not justified. 
You say that the enrollee was not enrolled in hospice on the date the services were provided. You also say that 
the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's 
responsibility to verify the member's coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
The enrollee ended Medicare Hospice benefits on September 8, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the transportation 
services on September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe. 
 
You asked the Plan to pre-approve Prolia. You say that this service is medically necessary. The Plan denied 
your request. The Plan says they have denied coverage under your medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on September 30, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that these services were emergent in nature. You say 
that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that there are in-network providers available for 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 had network providers 
available who could have provided 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 specialist services provided on September 30, 
2020, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on June 27, 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 filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 3, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services rendered on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on August 25, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed 
and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the referring provider is out-of-network. 
 
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 had network providers 
available who could have provided 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 durable medical equipment provided on August 
25, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from February 29, 2020, to March 29, 
2020. 
 
You asked the Plan to pay for the SNF care. You say that the SNF care provided from February 29, 2020, to 
March 29, 2020, was medically necessary. The Plan denied your request. The Plan says the enrollee did not 
meet criteria for SNF care provided from February 29, 2020 to March 29, 2020. 
 
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 the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, hypertension, 
Parkinson's disease and seizure disorder. From a nursing perspective, the enrollee received oral medications. 
The enrollee had stable vital signs. His lungs were clear. He was alert with confusion. Regarding rehabilitation 
services, the enrollee received physical therapy and speech therapy in the SNF at a non-skilled level. By the 
dates in question, the enrollee worked with therapy on being out of bed and up for several hours at a time.   
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the SNF care provided from February 29, 2020, to March 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a graft of skin substitute (15271) received 
on August 3, 2020. 
 
You asked the Plan to waive the copayment for a graft of skin substitute. You say that you were never informed 
of the cost for the requested procedure and were only told that the Plan had approved the procedure. 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 $325 
copayment for each date of surgical service received at an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for a graft of skin substitute. A graft of skin substitute falls 
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" 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 a graft of skin 
substitute (15271) received on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further reimburse you the contact lenses/fitting provided April 8, 
2020, to July 25, 2020. 
 
You asked the Plan to further reimburse you the contact lenses/fitting. You say that you would like this claim 
covered under your medical benefit. The Plan denied your request. The Plan says the claim has processed 
correctly. 
 
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 these services with a $100 allowance for lenses and frames purchased.  
 
We looked at the file and the Plan's rules. The file indicates that the Plan has reimbursed you their $100 
allowance for frames and contact lenses purchased. You are responsible for all remaining charges.  Based on 
this information, we decided that the Plan's rules for coverage of the contact lenses/fitting have processed 
correctly. Therefore, we decided that the Plan does not have to further reimburse you the contact lenses/fitting 
provided April 8, 2020, to July 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
November 9, 2020. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that you were under the 
impression you were covered by your previous health plan and should not be responsible for this copayment. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $20 
copayment for each Medicare-covered physical therapy and speech-language therapy visit.  
 
You have been asked to pay a $20 copayment for the physical therapy visit. The physical therapy visit falls 
within the Outpatient rehabilitation services benefit category. The record shows your plan became effective 
on November 1, 2020. 
 
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 physical therapy visit provided on November 9, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
October 29, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that even though a tiny 
polyp was removed, this should still be considered a screening colonoscopy. You say you only had this done 
because you doctor wanted it and you did not have any symptoms required a colonoscopy. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 $200 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 
You have been asked to pay a $200 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. The record shows a sessile rectal polyp was obtained and biopsied. 
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 diagnostic colonoscopy provided on October 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services coded A0429 provided on September 
6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code A0429 is ambulance service, basic life support, 
emergency transport (bls-emergency). 
 
We find that CPT code A0429-QL is not supported in the medical record. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services 
(A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare 
when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 
for services provided under these circumstances. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance services coded A0429 provided on September 6, 2020.
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 September 18, 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 had network providers 
available who could have provided 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 September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin (J9355). 
 
You asked the Plan to pre-approve Herceptin. You say that the medication is necessary. The Plan denied your 
request. The Plan says they are not responsible for covered routine costs associated with clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Herceptin as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Herceptin (J9355).