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

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
 
 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation.  
 Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee will need transportation to her 
medical visits. The Plan denied your request. The Plan says the enrollee has used up all her rides. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on the information provided, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on August 5, 
2020. 
 
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to 
reconsider their decision. The Plan denied your request. The Plan says the Evidence of Benefits must be 
submitted from the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, 
the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the office visit and related services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the office visit and related services 
provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had a problem with your ears 
and couldn't see your primary care physician. You say that you only saw the doctor's physician but are still 
being billed as if you saw the specialist. 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 $30 
copayment for each Tier 1 specialist visit. Covered services include medically necessary medical care or 
surgery services furnished in a physician?s office, certified ambulatory surgical center, hospital outpatient 
department, or any other location.  
 
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctors office visits" benefit category. The records show that you 
were seen at a specialist office. 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 office visit provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back orthosis provided on July 3, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the enrollee is unable to ambulate without pain and 
discomfort. The Plan denied your request. The Plan says the evaluation did not take place at a qualifying 
originating site. 
 
The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain 
sufficient documentation of the patient's medical condition to substantiate the necessity for the type and 
quantity of items ordered. 
 
We find that the orthosis is not supported in the medical record. A review of the file does not show that the 
assessment was provided in an authorized originating site. The orthosis ordered following the non-covered visit 
are likewise non-covered. Based on this information, we decided that Medicare rules for coverage of the 
orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the back orthosis 
provided on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on 
July 30, 2020. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you have never 
been charged for this exam before. 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 $40 
copayment per visit for Medicare-covered hearing services. Medicare-covered hearing services include 
diagnostic hearing and balance evaluations. 
 
You have been asked to pay a $40 copayment for the comprehensive hearing test. The comprehensive hearing 
test falls within the "Hearing 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 copayment 
for the comprehensive hearing test provided on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml solution. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia, 60 mg/ml solution.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 31, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were appropriate based on past 
medical history. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network 
providers, and authorization for certain services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the lab services at issue in this appeal. The Plan did not pre-approve the 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 the lab services provided on July 31, 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 physician services provided on February 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that it is the facility's responsibility to obtain prior 
authorization . The Plan denied your request. The Plan says prior authorization was not obtained by the enrollee 
or the rendering 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 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 physician services provided on February 28, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) for tooth  
number 9. 
 
You asked the Plan to pre-approve this service. You say that the extent of caries which includes three quarters 
of the coronal structure of this tooth will require a post to keep this tooth's crown from fracturing completely, 
possibly down to the gingival free margin. The Plan denied your request. The Plan says your request does not 
meet criteria for coverage of this procedure. 
 
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. 
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan?s rules for 
coverage of this service have not been met. Specifically, the only code requested was D2954 which is defined 
as prefabricated post and core in addition to a crown. Since this is not being requested with placement of a 
crown, the services described by this code are not appropriate in this case. Therefore, we decided that the Plan 
does not have to pre-approve a prefabricated post and core (D2954) for tooth number 9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 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 have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for dental surgery (41899) provided on January 28, 2020. 
 
You asked the Plan to pay for the dental surgery. You say that the medical records provided support the need 
for the services in dispute. The Plan denied your request. The Plan says that the services in dispute are non-
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 

 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental 
surgery (41899) provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2020, by an 
out-of-network (OON) 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 an out-of-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 laboratory services provided on March 17, 
2020, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fracture treatment (27808) provided January 27, 2020. 
 
You asked the Plan to pay for the fracture treatment. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27808 is closed treatment of malleolar ankle fracture. 
 
We find that CPT code 27808 is not supported in the medical record. Specifically, the provided records did not 
include any notes or details of the procedure at issue. Based on this information, we decided that Medicare 
rules for coverage of the fracture treatment have not been met. Therefore, we decided that the Plan does not 
have to pay for a fracture treatment (27808) provided January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) provided on 
July 29, 2020. 
 
You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids 
are not covered as they were purchased from a non-participating provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids were purchased from a provider that 
does not participate in the Plan?s network. The Plan contract states that all hearing services that are not covered 
by Medicare must be obtained by a Plan contract provider. Any care received from a non-participating provider 
will not be covered by the plan. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5298 x 2) provided on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on March 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on March 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous immune globulin (IVIG) 
services rendered from July 16, 2020, to July 17, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were not informed there 
would be a coinsurance. 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 a 20% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B.  
 
Review of the file shows that you received IVIG from July 16, 2020, to July 17, 2020. You have been asked to 
pay a 20% coinsurance for these services. These services fall within the chemotherapy drugs and all other 
drugs covered under Medicare Part B 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 intravenous immune globulin (IVIG) services rendered from July 16, 2020, to July 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure for treatment of sacroiliac joint mediated pain is experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure due to the wide variation in efficacy in the 
peer reviewed literature. Therefore, the request is considered not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgical services rendered 
from November 7, 2019 to November 8, 2019. 
 
You asked the Plan to waive the coinsurance for these services. You say that you had met your out-of-pocket 
maximum. 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 a 20% 
coinsurance for all other outpatient services, including observation and outpatient surgical services, not 
provided in an ambulatory surgical center.  
 
Review of the file shows that you received outpatient surgical services from November 7, 2019 to November 8, 
2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the all other 
outpatient services, including observation and outpatient surgical services, not provided in an 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 coinsurance for the outpatient surgical 
services rendered from November 7, 2019 to November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxycodone. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve oxycodone.  
 
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.