Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous decompression (0275T). 
 
You asked the Plan to pre-approve percutaneous decompression. You say that you are requesting to give your 
patient pain relief with the mild procedure CPT 0275T. Please see all documents for further review to approve 
this procedure. The Plan denied your request. The Plan says this request is not medically necessary because the 
records show the enrollee is not enrolled in a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare guidelines says this procedure is only covered when 
enrolled in a clinical study. The records show the enrollee is not enrolled in a clinical study. Based on this 
information, we decided that Medicare rules for coverage of percutaneous decompression have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous decompression (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SoClean CPAP sanitizing machine. 
 
You asked the Plan to pre-approve the machine. You say that this is needed to stay healthy. The Plan denied 
your request. The Plan says this is not a ocvered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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-approve a SoClean CPAP sanitizing machine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpreventative vaccines provided on July 13, 2020.You asked the Plan to pay forpreventative vaccines under Medicare Part B. You say that preventative vaccines should be covered by the Plan.The Plan denied your request. The Plan says the vaccines provided are not covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative vaccines under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illnessrelated to preventative vaccines under Medicare Part B.Therefore, we decided that the Plan does not have to pay forpreventative vaccines provided on July 13, 2020.Benefits for preventative vaccines may be available under Medicare Part D.Contactthe 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 the ophthalmology services (92004, 92250, 92285, 92015) 
provided on June 19, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the ophthalmology services. You say that you were advised prior authorization 
requirements had been waived. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 ophthalmology services (92004, 92250, 92285, 
92015) provided on June 19, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for portable diagnostic services provided on June 1, 2020. 
 
You asked the Plan to pay for the portable diagnostic services. The Plan denied your request. The Plan says 
services rendered by non-participating 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 
service 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 portable diagnostic services provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery. 
 
You asked the Plan to pre-approve an extra battery. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says extra batteries are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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-approve an extra battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens (V2520) provided on June 26, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the contact lens. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 contact lens (V2520) provided on June 26, 
2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee 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 the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treadmill provided on August 14, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the treadmill. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent 
and prior authorization was not obtained to receive out-of-network care. 
 
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 treadmill provided on August 14, 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 skilled nursing facility (SNF) services provided from 
May 16, 2020, to June 14, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services 
were not medically necessary. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that as of May 16, 2020, the enrollee did 
not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable 
gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF 
level of care as of May 16, 2020. He did not have any parenteral medications, complex wound care or nutrition 
given via a feeding tube.  The member received skilled care and improved, however his function was at his 
baseline and he was able to tolerate an oral diet by May 16, 2020, and did not require any further inpatient 
skilled rehab services. 
 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from May 16, 2020, to June 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zostavax injection (90750, 90471) provided April 30, 2020. 
 
You asked the Plan to pay for the Zostavax injection. You say that the injection should be covered. The Plan 
denied your request. The Plan says this injection is not covered under the Part B medical benefit. It may be 
eligible for reimbursement under the Part D drug benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zostavax 
injection. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Zostavax 
injection. Therefore, we decided that the Plan does not have to pay for a Zostavax injection (90750, 90471) 
provided April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 10, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the vision services. You say that you did not ask for a medical exam therefore 
you should not owe any money. The Plan denied your request. The Plan says you did not request prior 
authorization for the out-of-network services therefore you are responsible for the charges. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 vision services provided on August 10, 2020 by an out of network provider. 
Please note, the provider is only holding you responsible for $5 of the total charge.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for specialist services provided on 
June 16, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation for services rendered. 
 
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 $45 
copayment for specialist services.  
 
You have been asked to pay $45 copayment for this copayment. this copayment falls within the specialist 
services 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 $45 copayment charged for specialist 
services provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arch support foot insert (L3030). 
 
You asked the Plan to pre-approve an arch support foot insert. You say that this is needed for the enrollee's 
pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that inserts and other shoe modifications  are covered if they are on a shoe that is an 
integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. 
 
Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for the 
enrollee, neither Medicare nor the Plan provides coverage of orthotics for her condition. Therefore, we decided 
that the Plan does not have to pre-approve an arch support foot insert (L3030).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alcohol and/or other drug treatment with CPT code 
H2036 provided. 
 
You asked the Plan to pay for CPT code H2036. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
We looked at the file and Medicare rules. In this case, CPT code H2036 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Based on this information, we decided that 
Medicare rules for coverage of CPT code H2036 have not been met. Therefore, we decided that the Plan does 
not have to pay for the alcohol and/or other drug treatment with CPT code H2036 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye exams (92012) performed on May 13, 
May 20, and June 3, 2020. 
 
You asked the Plan to waive the copayments for eye exams. You say that these copayments should have been 
waived pursuant to the Plan's notice of cost-sharing waivers effective May 1, 2020. The Plan denied your 
request. The Plan says the correct copayments were 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 $35 
copayment for Medicare-covered vision services.  
 
The Plan has waived cost-sharing for primary care provider office visits, behavioral health office visits, and 
telehealth visits. Eye exams do not fall within any of the applicable benefit categories. Therefore, you have 
been asked to pay $105, or a $35 copayment for each one of 3 eye exams. Eye exams fall within the "Vision 
care" 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 copayments for eye exams (92012) performed 
on May 13, May 20, and June 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you have never been charged a 
copayment for a preventative service. 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 a $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical center.  
 
You received an EGD on July 28, 2020. An EGD is considered a diagnostic procedure, not preventative. 
Therefore, you are responsible to pay the allowed amount of $204.28, which is less than the $225 copayment.  
 
You have been asked to pay $204.28 for an EGD. An EGD falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical center 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 an EGD provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe co-payments charged for physician services and x-ray provided on June 29, 2020.You asked the Plan to waivethese copayments. You say that you do not believe these copayments are correct because these services were delayed due to Covid 19.The Plan denied your request. The Plan says these copaymentsare a contractual obligation for services rendered.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 $40 copayment for specialist services and $50 copayment for x-rays. You are being asked to pay less than the normal copayment for the imaging services and the traditional copayment for the specialist services. 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 waivethe co-payments charged for physician services and x-ray provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear with up-graded progressive lenses purchased on 
June 23, 2020. 
 
You asked the Plan to pay for up-graded lenses. You say that these lenses should be covered by the Plan. The 
Plan denied your request. The Plan says progressive lenses are not covered. 
 
Medicare does not cover routine vision and eyewear services. Medicare does not cover progressive lenses. The 
Plan contract does not cover progressive lenses. Therefore, we decided that the Plan does not have to pay for 
eyewear with up-graded progressive lenses purchased on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network dialysis. 
 
You asked the Plan to pre-approve out of network services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says this service can be provided in 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 provider at issue in this case is not a network provider with the Plan. 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 out of network services. Our reviewer says that Medicare coverage criteria 
are not met. Our physician reviewer found based on the medical records, the enrollee is already non-compliant 
at the current facility.  There is no service the current facility is providing that will not be available at an in-
network 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 out of network services have not been met. 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 out of network services. Therefore, we decided that the Plan does 
not have to pre-approve out of network dialysis.