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

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that you fell and hit your head while at a casino. The casino called for the ambulance that did not transport you. You say that you should not be charged for the ambulance response because you did not call for it and it wasn't needed.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 January 8, 2019. 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 forthe ambulance services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on August 16, 2019 by the out of network provider.
You asked the Plan to pay for outpatient lab tests. You say that you are requesting payment and are seeking for review. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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 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 outpatient lab tests provided on August 16, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided
on May 20, 2019.
You asked the Plan to pay for the medical nutrition therapy services. The Plan denied your request. The Plan
says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the
Plan does not have to pay for the medical nutrition therapy services provided on May 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory blood pressure monitoring provided on November 4, 2018.
You asked the Plan to pay for ambulatory blood pressure monitoring. You say that the Plan should pay this
claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for
suspected white coat hypertension and must be performed for at least 24 hours.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We looked at the file and Medicare rules. Blood pressure monitoring during transport is not separately payable.
Based on this information, we decided that Medicare rules for coverage of ambulatory blood pressure
monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the blood pressure
monitoring provided on November 4, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG provided on September 17, 2019.
You asked the Plan to waive the copayment for the ECG. You say that this was supposed to be a routine ECG.
You say that you were informed this would be covered. The Plan denied your request. The Plan says the
copayment 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 $50
copayment for diagnostic procedures and tests at an in-network outpatient hospital.
You have been asked to pay a $50 copayment for the ECG. The ECG falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the ECG provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve and stabilizer (L1833,
L2810, L2397) provided to the enrollee on February 25, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the medical record does not support the supplies identified in the physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the face-to-face
encounter documentation includes information supporting that the beneficiary was evaluated or treated for a
condition that supports the DME item(s) ordered.
The record shows that there was no examination or note of knee pain in the medical record. Therefore, we
decided that the Plan does not have to pay for a knee orthosis with suspension sleeve and stabilizer (L1833,
L2810, L2397) provided to the enrollee on February 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an arthroscopy (29999) provided on March 1, 2019.
You asked the Plan to pay for the arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not indicate that an unlisted procedure, arthroscopy was performed.
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 2999 is unlisted procedure, arthroscopy. We asked our coder 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 arthroscopy. Our reviewer says that CPT cpde 29999 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not validate that an unlisted procedure, arthroscopy was performed on March 1, 2019.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for an arthroscopy (29999) provided on March 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for echocardiography provided on August 14, 2019.
You asked the Plan to waive the coinsurance for echocardiography. You say that you disagree with the denial of 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 non-radiological diagnostic services. You received echocardiography on August 14, 2019. The allowed amount is $472.36 and 20% of that is $94.47. You have been asked to pay the total coinsurance amount of $94.47 for echocardiography. Echocardiography 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 echocardiography provided on August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Wixela Inhub for the enrollee.
You asked the Plan to pre-approve Wixela Inhub. You say that Wixela Inhub is medically necessary. The Plan denied your request. The Plan says Wixela Inhub is not covered under Medicare Part B.
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 Wixela Inhub for the enrollee.
Benefits for Wixela Inhub 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 pre-approve a referral to an out-of-network provider
You asked the Plan to pre-approve these services. You say that the enrollee would like a second opinion regarding management of osteoporosis. The Plan denied your request. The Plan says the services are available from network providers.
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 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. 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 provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 12, 2019 through April 16, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on April 12, 2019 and discharged on April 16, 2019. You were asked to pay a $285 copayment per day from April 12, 2019 through April 15, 2019, days 1-4 of your inpatient hospital care. You were discharged on April 16, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $285 copayment per day required for days 1-7. 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 inpatient hospital care from April 12, 2019 through April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 25, 2019 by an out-ofnetwork
provider.
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 services were rendered by a non-network provider without 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 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 25, 2019 by
an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of support implant of tooth #'s 30 and 28, lower jaw bone graft, and mouth surgery procedure.
You asked the Plan to pre-approve the removals of support implants, lower jaw bone graft, and mouth surgery procedure. You say that if the enrollee is left in his current condition, he is at increased risk for infection and systemic consequences of peri-implantitis and possible systemic infection and sequelae. You also say that you feel it is medically necessary to graft and place dental implants for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary.
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 pre-approve removal of support implant of tooth #'s 30 and 28, lower jaw bone graft, and mouth surgery procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September
30, 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 screening tests are 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 solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on September 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on May 8, 2019 by an out of network provider.
You asked the Plan to pay for the home visit. You say that you were not aware that the Plan needed a prior authorization. The Plan denied your request. The Plan says a prior authorization for the service was not obtained prior to the service being rendered. The Plan also says that the service is not covered.
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 home visit provided on May 8, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on August 30, 2019.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says criteria for the orthosis was not met.
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 ankle foot orthosis (L1971). Our
physician reviewer found the enrollee's chief complaint was chronic pain located in left and right ankles.
The documentation in the case file does not support that the requested ankle/foot orthoses were medically
reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A
physical examination of the ankles and feet would reasonably be required to adequately assess whether the
coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically
reasonable and necessary in this case, as there is no documentation of a credible physical examination of the
ankles and feet.
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 ankle foot orthosis (L1971) have not been met. Therefore, we decided that
the Plan does not have to pay for the ankle foot orthosis provided on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 6, 2018
through August 8, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on August 6, 2018 and discharged on August 8, 2018. You
were asked to pay a $250 copayment per day from August 6, 2018 through August 7, 2018, days 1-2 of your
inpatient hospital care. You were discharged on August 8, 2018 and there was no copayment charge for the day
of discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care from August 6, 2018 through August 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for an office visit on September 10, 2019.
You asked the Plan to waive this copayment. You say that this copayment is not correct. The Plan denied your request. The Plan says this copayment was based on the services provided and the Plan contract agreement.
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 $10 copayment for physician visits in network.
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 $10 copayment charged for an office visit on September 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular stress test (93017) provided on August 16,
2019.
You asked the Plan to pay for the cardiovascular stress test. You say that considering your condition, you feel
this test should be paid. The Plan denied your request. The Plan says third party services are not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in
clear, accurate terms all cost-sharing information.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the cardiovascular stress test have not been met. Specifically, the Plan's EOC clearly states that
physical exams and other services required by third parties are not covered under any condition. Therefore, we
decided that the Plan does not have to pay for a cardiovascular stress test (93017) provided on August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rivastigmine.
You asked the Plan to pre-approve Rivastigmine. You say that Rivastigmine is medically necessary. The Plan
denied your request. The Plan says Rivastigmine is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Rivastigmine.
Benefits for Rivastigmine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone for the enrollee.
You asked the Plan to pre-approve Oxycodone. You say that oxycodone is medically necessary for the
enrollee. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Oxycodone for the enrollee.
Benefits for Oxycodone 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 pre-approve a power scooter for the enrollee.
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 face-to-face evaluation.
The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the beneficiary and their treating physician is required prior to prescribing durable medical equipment. We looked at the file and Medicare rules. The file does not contain documentation of a face-to-face evaluation and the enrollee's locality is not eligible for telehealth services. Therefore, we decided that the Plan does not have to pre-approve a power scooter for the enrollee.