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

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays 
provided on December 6, 2019. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays. You say that you 
were not notified that they were no longer taking Medicare. You say that you shouldn't have to pay for this. 
The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider 
who 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. The 
rendering provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have 
to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair repair and parts provided on December 
6, 2019. 
 
You asked the Plan to pay for the repair charge (K0739), power wheelchair components (E2370), battery 
(E2365), and battery charger (E2366). You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says they have insufficient documentation to corroborate the services. 
 
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 physician order for the supplies provided in this case. The physician order 
is dated after the date of service. Also, the service ticket says the service was performed on December 4, 2019 
not the claim date of service. 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 power 
wheelchair repair and parts provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the knee orthoses, 
and the lumbar-sacral orthosis provided on December 31, 2019. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960), the knee orthoses (L1851), and 
the lumbar-sacral orthosis (L0648). You say that the orthoses were medically necessary. The Plan denied your 
request. The Plan says rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered.  
 
 
 
Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis, the knee 
orthoses, and the lumbar-sacral orthosis provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and extraction (D7140) provided on April 1, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
extraction. You say that these services were rendered on an emergency basis. The Plan denied your request. 
The Plan says these services are not covered by the Plan. The Plan also says that no benefits are available for 
procedures performed by OON providers. 
 
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. The Plan also says that services received by an OON provider are not 
covered. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140), first intraoral periapical x-ray (D0220), and extraction (D7140) provided on April 1, 2020 
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 5, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the spinal surgery. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there was no medical necessity or 
urgency/emergency that required this planned surgery to be completed by an out-of-network provider at an out-
of-network facility. 
 
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 
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 November 5, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from September 9, 
2019 to October 7, 2019. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were not informed you had 20 
days of insured hospitalization. You say the 8 additional days were not warranted and that it is a financial 
hardship. 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 $0 
copayment per day, days 1-20 and a $167.50 copayment per day, days 21-100 for each SNF stay.  
 
You have been asked to pay a $1,340 copayment for the SNF stay. The SNF stay falls within the ?Skilled 
nursing facility (SNF) care? benefit category. See chart below. 
 
Dates of Service Service Copayment 
per Day 
SNF Days Number of 
Days 
Member 
Liability 
September 9, 2019 to 
September 28, 2019 
SNF stay $0 1-20 20 $0 
September 29, 2019 to 
October 7, 2019 
SNF stay $167.50 21-28 8 $1,340 
Total     $1,340 
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 SNF stay provided from September 9, 2019 to October 
7, 2019. 
 
Your complaint about the social worker?s negligence is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
February 17, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because this ambulance transport was 
not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says that 
this ambulance transport does not meet the Medicare criteria for payment. Our physician reviewer found upon 
ambulance arrival; the enrollee was hemodynamically stable with stable vital signs. The documentation does 
not support that the enrollee needed the expertise, services, and life-saving and life-sustaining equipment that 
only a fully-equipped ambulance can provide for safe transportation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for non-emergency ambulance transportation provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; single view (CPT Code 
71045) provided to the enrollee on November 6, 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 services are not supported by the records. 
 
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 71045 is not supported in the medical record. Specifically, the member had a chest x-
ray on November 6, 2019. The submitted documentation supports 1 (one) unit of 71045-26, which was 
previously approved/paid. There is no additional documentation supporting an additional study which was 
billed and remains denied. Based on this information, we decided that Medicare rules for coverage of the chest 
x-ray have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, 
chest; single view (CPT Code 71045) provided to the enrollee on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization inpatient care provided from December 
30, 2019 to January 3, 2020. 
 
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee was stable prior to admission. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization inpatient care. Our 
reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. The 
provided records did not clearly show that the patient was not stable for transfer. Vitals were stable throughout 
and no clinical findings or test results suggest she was unstable at any time. Our physician reviewer found that 
the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan 
facility. 
 
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 post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided from December 30, 2019 to 
January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on February 21, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 February 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 ambulance 
service provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from 
February 12, 2020 to February 28, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 
charges because you were never charged with your previous plan. 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 from February 12, 2020 to February 28, 2020. Therefore, you are 
responsible to pat your share of the cost-sharing charges. Please see the chart below.  
 
Date of Service Billing Code Allowed Amount Amount You Owe 
2/12/2020 A4394 $12.24 $2.45 
2/12/2020 A5063 $32.20 $6.44 
2/28/2020 A4407 $52.00 $10.40 
 
The total amount you owe is: $19.29.  
 
You have been asked to pay the total coinsurance amount of $19.29 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 from February 12, 2020 to February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered on 
January 2, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the cost for Part B covered chemotherapy drugs and other Part B covered drugs.  
 
Review of the file shows that you received chemotherapy services on January 2, 2020. You have been asked to 
pay 20% of the cost for these services, for a total of $1,444.86. These services fall within the Part B covered 
chemotherapy drugs and other Part B covered drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the chemotherapy services rendered on January 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on December 22, 
2018. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was submitted on 
December 14, 2019 and is within timely filing limit of 120 days from the date of service. You say that proof of 
timely filing and the original EOB have been submitted to support your argument. The Plan denied your 
request. The Plan says the provider submitted the claim after timely filing limitations. 
 
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 the emergency department visit was not filed until December 23, 2019. This 
means that more than one calendar year from the date of service had passed before a claim was filed. The 
documentation you submitted was not sufficient evidence of the claim having been delivered to and received 
by the Plan within the timely filing limits. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on December 22, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two abutment supported porcelain fused to metal crowns 
(D6059 x2) provided on February 28, 2020. 
 
You asked the Plan to pay for the abutment supported porcelain fused to metal crowns. You say that you spoke 
with customer representative prior to receiving the service, and were told that crowns would be covered. 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 two 
abutment supported porcelain fused to metal crowns (D6059 x2) provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device provided on March 
11, 2020. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for preventing deep vein thrombosis during or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
A PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism 
is a preventive service. Items that are used for a preventative service or function are excluded from coverage 
under the Medicare DME benefit.  
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device provided 
on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided from February 
27, 2020 to April 10, 2020. 
 
You asked the Plan to pay for out of network chiropractic services. You say that these services should be 
covered by the Plan. The Plan denied your request. The Plan says you had prior authorization to see a provider 
in network. You did not have prior authorization to see a provider 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue out of 
network. The Plan did approve this service in network. You chose to use an out of network provider. 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 out of network chiropractic services provided from February 27, 2020 to April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 20, 2020.
You asked the Plan to pay for the laboratory service. 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 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 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of daratumumab provided on 
November 7, 2019. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you are appealing. The Plan denied 
your request. The Plan says the coinsurance amount you are being charged is correct. 
 
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 Part B drugs. The allowed amount of this drug is $6,874.40, resulting in a coinsurance 
obligation of $1,374.88. 
 
You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls within the Medicare Part B 
Prescription Drugs 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 an injection of 
daratumumab provided on November 7, 2019.