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

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a hip orthosis with suspension sleeve (L1686, L2624) provided to the enrollee on October 28, 2019 to October 29, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a hip orthosis with suspension sleeve (L1686, L2624) provided to the enrollee on October 28, 2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deducible for the office visit and injections provided on
November 11, 2019.
You asked the Plan to waive the deducible for the office visit and injections. You say that this is your primary
care provider. You say that you were expecting a $0 copayment. The Plan denied your request. The Plan says
the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that your deductible is $750, which applies to all items and services except those
specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will
pay our share for your covered medical services. Out-of-network services are not excluded from the deductible.
The item or service you asked the Plan to waive the deducible for falls within the "Physician/Practitioner
services, including doctor's office visits" and "Medicare Part B prescription drugs" benefit category. The Plan
has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-ofnetwork
services. This cost sharing is a contractual obligation that had not been met at the time the office visit
and injections were received on November 11, 2019. Therefore, we decided that the Plan does not have to
waive the deducible for the office visit and injections provided on November 11, 2019.
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 for the ambulance services. You say that you have hyperglycemia and your blood
sugar dropped below range. The EMT responders treated you and when they tested your sugar count it was
extremely low. They treated you and got your blood sugar in range and gave you food to stabilize your level.
You say that if they had taken you to the hospital, the hospital probably wouldn't have been able to do more for
you. You say that you were stabilized and didn't need transportation. By not being transported, you believe you
saved the plan and yourself money. 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 October 27, 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 for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on October 16, 2019.You asked the Plan to pay forthe services. You say that this is an in-network provider.The Plan denied your request. The Plan says out-of-network services are not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan 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 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 haveto pay forthe medical services provided to you by an out-of-network provider on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services. You say that you prefer to be treated at this officer because the in-network physician gave your foot injections that made your feet worse. The Plan denied your request. The Plan says out-of-network providers are available only when your medical group does not have the appropriate expertise in their 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested 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. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 17, 2019. You asked the Plan to pay for the x-ray. You say that the service was medically necessary and billed correctly. The Plan denied your request. The Plan says this a duplicate of a previous claim. 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 records show that the claim as billed is a duplicate of a previous claim already processed. 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 a chest x-ray (71045) provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.You asked the Plan to pre-approvea power seat elevation feature (E2300). You say that the enrollee needs a power seat elevation featurefor independence with activities and socialization. The Plan denied your request. The Plan says power seat elevation feature are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea power wheelchairpower seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the alginate dressings and gauze provided for the treatment of a stage 3 heel ulcer provided on October 4, 2019.
You asked the Plan to pay for the wound dressings. You say that this was incorrectly denied as this is covered by Medicare Part B. The Plan denied your request. The Plan says that Medicare does not cover this because it does not meet the statutory definition of durable medical equipment (DME).
The Plan must follow Medicare rules. Medicare rules say that surgical dressings are covered under the Surgical Dressing Benefit for qualifying wounds. Although it is correct that surgical dressings do not meet the definition of DME, Medicare does not cover them under the DME benefit, but rather under the Surgical Dressings benefit. These dressings are being provided for use with a wound which has been surgically debrided. We find that the Plan's denial as not a Medicare-covered benefit is not supported in this case. Therefore, we decided that the Plan has to pay for the alginate dressings and gauze provided for the treatment of a stage 3 heel ulcer provided on October 4, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the skin biopsy or the facility fee provided
by on August 30, 2019.
You asked the Plan to waive the copayments for the skin biopsy and the facility fee. You say that you should
not be responsible for the copayments for this procedure. 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 $40
copayment for each in-network specialist visit for Medicare-covered benefits and a $275 copayment for each
Medicare-covered outpatient surgery in an in-network ambulatory surgical center or in-network hospital
outpatient facility.
You have been asked to a total of $248.65 copayment for the skin biopsy and the facility fee. The skin biopsy
falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The facility
fee falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
August 30, 2019 Skin biopsy $23.97 $40.00 $23.97
August 30, 2019 Facility fee $224.68 $275.00 $224.68
Total $248.65
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 copayments for the skin biopsy or the facility fee provided on August 30,
2019.
Your complaint about the distress of the procedure and the outcome of the procedure are 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on January 28, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on January 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from November 25, 2019 to December 2, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered  from November 25, 2019 to December 2, 2019. 

Benefits for these services 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 physician's services to be provided by doctor.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by doctor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser eye surgery.
You asked the Plan to pre-approve the laser eye surgery. You say that you reside where you do because you cannot handle the winters where you were previously living and you do not believe it is fair to have to travel back there for surgery as it will be costly to come back home. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve laser eye surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the hand surgery provided on December 11, 2019.
You asked the Plan to waive the deductible for the hand surgery. You say that you had already met your deductible. 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. Your contract with the Plan says that there is a $750 deductible that applies towards each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The hand surgery you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. This cost sharing is a contractual obligation that had not been met at the time the hand surgery was received on December 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the hand surgery provided by on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two retainer crowns (D6740 x2) and pontic (D6245).
You asked the Plan to pre-approve the retainer crowns and pontic. You say that when your dentist removed a
very old crown from tooth #13, he discovered that the tooth was rendered unsalvageable by extensive decay.
You say that your dentist offered you two options, you are unable to afford an implant but might be able to
afford a bridge if your insurance paid for the two crowns. The Plan denied your request. The Plan says these
services are not covered by 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 pre-approve the
two retainer crowns (D6740 x2) and pontic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you need these orthotics due to your toe and
circulation problems. The Plan denied your request. The Plan says these orthotics are not covered for your
condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Inspire hypoglossal nerve stimulator (CPT 64568 and CPT 0466T). You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider CPT 0466T to be medically reasonable or necessary. Additionally, services related to non-covered services are not covered services under Medicare. Therefore, 64568 is non-covered when requested in conjunction with the non-covered code 0466T. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Inspire hypoglossal nerve stimulator (CPT 64568 and CPT 0466T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Power Mobility Device (K0800).You asked the Plan to pre-approvethe power mobility device. You say that the scooter is medically necessary.The Plan denied your request. The Plan says the record shows the requested mobility device is primarily for use outside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea Power Mobility Device (K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that this is medically necessary.The Plan denied your request. The Plan says the record does not show the enrollee has had a failed surgery.The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered when there has been a failed spinal fusion.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 a spinal electrical osteogenesis stimulator. Our reviewer says that the requested stimulator is not medically necessary. Our physician reviewer found there is no clear diagnosis of nonunion and failure of spinal fusion. Computed tomography is needed to clearly show the failure of fusion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to pre-approve an office visit, duplex scan and injections to be provided
by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit, duplex scan and injections. You say that these services are
medically necessary. The Plan denied your request. The Plan says 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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
an office visit, duplex scan and injections to be provided by an out of network (OON) provider.