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

 
We decided that the Plan does not have to pre-approve a tier exception for Sirolimus for the enrollee. 
 
You asked the Plan to pre-approve a tier exception. You say that the enrollee requires this medication. The Plan 
denied your request. The Plan says that Part B covered products are not eligible for reduction to a lower co-
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D 
drugs.  
 
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for 
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-
approve a tier exception for Sirolimus for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe low dose CT scan provided on October 29, 2019.You asked the Plan to pay forthe low dose CT scan for lung cancer screening. You say that your physician ordered this test and you cannot afford this bill.The Plan denied your request. The Plan says you had a low dose CT scan in April 2019 and you are only covered for a scan every 12 months.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. The Plan'srules apply. You are only covered for this scan every 12 months. Based on this information, we decided that Medicare rules for coverage of the low dose CT scan have not been met.Therefore, we decided that the Plan does not have to pay forthe low dose CT scan provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on April 2, 2020, to September 2, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree that 
you should be charged for this. The Plan denied your request. The Plan says the correct coinsurance has been 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $102. The total amount you are being asked to pay is $20.40 ($102 x 20% = $20.40). 
Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
April 2, 2020, to September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture, complete mandibular 
denture, and six extractions to be provided by you, an OON provider. 
 
You asked the Plan to pre-approve the complete maxillary denture, complete mandibular denture, and 
extractions. The Plan denied your request. The Plan says you are not a part of the Plan's network. The Plan also 
says that the claim does not meet the urgent or emergent criteria based on the procedure codes and diagnosis 
codes submitted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture, complete mandibular denture, and six extractions to be provided by you, an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve UV light sanitizer (CPT Code E0691). 
 
You asked the Plan to pre-approve the UV light sanitizer. You say that this is necessary. The Plan denied your 
request. The Plan says the requested device is an item of convenience and not a covered Medicare 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 UV light sanitizer (CPT Code E0691).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on January 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
requested air ambulance services were not medically reasonable and necessary. Our physician reviewer found 
that the documentation did not support that the enrollee suffered from an illness or injury that contraindicated 
transportation by any means other than ambulance. The documentation did not support that the enrollee's 
condition was such that the time needed to transport a patient by ground, or the instability of transportation by 
 
 
ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The 
documentation did support that the transferring hospital did not have adequate facilities to provide the medical 
services needed by the enrollee. 
 
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 pay for the air ambulance services provided on January 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (X-Ray) of chest (71046) 
provided on February 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for X-Ray of chest. You say that you were not aware you had to get prior 
authorization. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 radiologic examination (X-Ray) of chest 
(71046) provided on February 22, 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 the injection services (J3490 x 56 units, J3411 x 4 units, 
J3415 x 4 units, and J3420 x 1 unit) provided on February 26, 2020. 
 
You asked the Plan to pay for the injection services. 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 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 injection services. Our reviewer says that 
the medical records do not support the billing of CPT codes J3490 x 56 units, J3411 x 4 units, J3415 x 4 units, 
and J3420 x 1 unit. Our physician reviewer found Healthcare Common Procedural Coding System for codes 
J3490 (56 units), J3411 (4 units), J3415 (4 units), and J3420 (1 unit) billed to the health plan for services 
provided on February 26, 2020 does not meet criteria for billing and reimbursement consideration.  The 
medical records submitted include documentation that a nutria-pharmaceutical blend was injected, therefore, it 
is no longer appropriate to bill these drugs separately for reimbursement consideration.  Medicare says HCPCS 
code J7999 - compounded drug, not otherwise classified should be used to report this service. 
 
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 injection services have not been met. Therefore, we decided that the Plan 
 
 
does not have to pay for the injection services (J3490 x 56 units, J3411 x 4 units, J3415 x 4 units, and J3420 x 1 
unit) provided on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services provided 
August 5, 2019 to August 6, 2019. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that the 
copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing has been 
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 $315 
copayment per day, for days 1-5 for inpatient mental health services.  
 
You have been asked to pay $315 copayment for one day of inpatient mental health services. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for inpatient mental health services provided August 5, 2019 to August 
6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy duty walker identified with code E0147.You asked the Plan to pre-approvea heavy duty walker. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested item.The Plan follows Medicare rules. Medicare rules say that heavy duty walkers are only covered for certain indications.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 heavy duty walker. Our reviewer says that the documentation does not support that the requested heavy duty walker is medically reasonable or necessary. Our physician reviewer found the documentation does reveal that you have a mobility limitation, but it is not clear that it significantly impairs your ability to participate in one or more mobility-related activities of daily living (MRADL) inthe home. There is no evidence that you are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Therefore, you do not meet criteria for the requested walker.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 heavy duty walker have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty walker identified with code E0147.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that you were referred to the oral surgeon by your 
dentist. The Plan denied your request. The Plan says services are only covered when they are performed by a 
participating general dentist. The Plan also says that dental services provided by an oral surgeon are not 
covered. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services received from May 22, 2020 to June 
24, 2020. 
 
You asked the Plan to pay for the services. You say that you have found something that works. The Plan denied 
your request. The Plan says the total maximum benefit has been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. The plan has already paid $150 during the year towards the 
acupuncture benefit. Based on this information, we decided that the rules for coverage of the acupuncture 
services have not been met. Therefore, we decided that the Plan does not have to pay for acupuncture services 
received from May 22, 2020 to June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code S8429, 
A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have venous insufficiency and 
lymphedema. The Plan denied your request. The Plan says these types of stockings are only covered when 
there is a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code S8429, 
A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
 
 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code S8429, A6549.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of face (70487) 
provided on February 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for CT of face. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for services rendered by an out-
of-network provider. 
 
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 computed tomography (CT) scan of face 
(70487) provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 93010) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that only one unit of 
this code is allowed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The above cited Medicare rule does not apply in this case. A repeat EKG was 
provided on the date of service in question with a separate interpretation and report. This is why the same 
provider billed the code with the -76 modifier, which indicates a repeat procedure or service by the same 
physician. The services were billed appropriately and the Plan has not provided documentation to substantiate 
its denial. Therefore, we decided that the Plan has to pay for the services (CPT 93010) provided.  
 
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 $45 copayment charged for specialist services provided on 
July 20, 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 was charged based on the services provided. 
 
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 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 July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of incremental dosages of allergen (95115) 
provided on July 6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the injection of incremental dosages of allergen. You say that the services 
provided were medically necessary. 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 injection of incremental dosages of allergen 
(95115) provided on July 6, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic nuclear medicine procedure 
and radiopharmaceutical provided. 
 
You asked the Plan to waive the copayment for the radiology services. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $180 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $180 copayment for the radiology services. The radiology services fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the diagnostic nuclear medicine procedure and radiopharmaceutical provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided  
on June 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 June 11, 2020. 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 provided on June 11, 2020.