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

We decided that the Plan does not have to reimburse you forthehearing aids provided on December 12, 2019.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not ordered through the designated vendor.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. The Plan pays for hearing aids only when ordered through the Plan's designated vendor.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for the hearing aids providedon December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant controller and related accessories for a 
power wheelchair (E2331, K0108, K0108). 
 
You asked the Plan to pre-approve the attendant controller and related accessories. You say that these items are 
medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered.  
 
We looked at the file and Medicare rules. The record shows a beneficiary-operated controller was already 
requested and approved. An attendant control cannot be approved in addition to a beneficiary-operated system. 
The related controller accessories (K0108) are not necessary as the already approved expandable controller and 
harness (E2313, E2377) provide the same function. Based on this information, we decided that Medicare rules 
for coverage of the attendant controller and related accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attendant controller and related accessories for a power wheelchair 
(E2331, K0108, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any 
type (CPT Code E2300). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says this item is 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.   
 
Seat Elevator (CPT Code E2300) is requested to promote increased functional reach to tables/sinks; will 
promote greater independence w/transfers. E2300 Seat Elevator does not serve a primary medical purpose and 
is statutorily non-covered. In addition, if the sole function of E2310 Power wheelchair accessory, electronic 
connection between wheelchair controller and one power seating system motor, including all related 
electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware is for a 
power seat elevator, it will be denied as non-covered as well. Therefore, we decided that the Plan does not have 
to pre-approve wheelchair accessory, power seat elevation system, any type (CPT Code E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (K0554). 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the glucose monitor is 
medically necessary. The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered when 
the enrollee is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The record shows the enrollee does not use multiple daily insulin 
injections. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose 
Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous 
Glucose Monitor (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress (E0261, 
E0272). 
 
You asked the Plan to pre-approve the semi-electric hospital bed and mattress. You say that the bed is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed and mattress. Our 
reviewer says that the bed is not medically necessary. Our physician reviewer found the patient's condition does 
not require positioning of the body in ways not feasible in an ordinary bed. The patient does not require 
frequent changes in body position and there will not be a need for immediate changes in body position. The 
patient's condition does not require special attachments that cannot be fixed and used on an ordinary bed. 
 
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 hospital bed and mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed and mattress (E0261, E0272).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for medical 
supplies provided by participating providers on May 8, 2020, to July 20, 2020. 
 
You asked the Plan to waive the copayment for an office visit and coinsurance for medical supplies. You say 
that you were told this would cost anything. You say that this was a telehealth visit and you don't feel like you 
should owe a copayment for that. The Plan denied your request. The Plan says the correct copayment and 
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 $5 
copayment for physician/practitioner services/in-network/PCP and a 20% coinsurance for durable medical 
equipment/in-network.  
 
You have been asked to pay a $5 copayment for a telehealth office visit and a 20% coinsurance of the allowed 
amount for medical supplies. The total allowed amount is $120.20. The amount you are being asked to pay for 
medical supplies is $24.04 ($120.2 x 20% = 24.04). The total amount you are being asked to pay is $29.04 ($5 
+ $24.04 = $29.04). 
 
An office visit falls within the physician/practitioner services/in-network/PCP benefit category and medical 
supplies falls within the durable medical equipment/in-network 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 office visit and coinsurance for medical supplies provided by participating 
providers on May 8, 2020, to July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you want to see this out-of-network 
provider. The Plan denied your request. The Plan says they have in-network specialists that can provide the 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. There is concern that the patient will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan. 
 
You asked the Plan to pre-approve a low dose CT scan. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that low dose CT scans are only covered for certain 
indications.  
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is between the 
ages of 55 and 77 years old. Based on this information, we decided that Medicare rules for coverage of a low 
dose CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose 
CT scan.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of one breast (76641) 
provided on February 7, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound of one breast. You say that you feel you were 
overcharged. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $110 
copayment for other outpatient diagnostic tests.  
 
You have been asked to pay a $110 copayment for the ultrasound of one breast. The ultrasound of one breast 
falls within the other outpatient diagnostic tests 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 ultrasound of one breast (76641) provided on February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE).You asked the Plan to pre-approvethe TTE. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a TTE is covered for the indications listed in L33577.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 TTE. Our reviewer says that the requested TTE is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is clinically stable without documented valve diseaseand with no symptoms, no physical exam abnormalities and no ECG changes. In this circumstance, the documentation does not support the medical necessity for a repeat echocardiogram.  Coverage criteria are not met since there are no documented covered indications for the procedure.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 TTE have not been met.Therefore, we decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on June 16, 2020. 
 
You asked the Plan to pay for the gingival irrigation (D4921). You say that you need the implants and denture 
cleaned twice a year. You say that you were informed this was covered. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for aflibercept injection (J0178) and 
copayment for intravitreal injection of a pharmacologic agent (67028). 
 
You asked the Plan to waive the cost sharing for aflibercept injection and for intravitreal injection of a 
pharmacologic agent. You say that you were informed the service was covered. The Plan denied your request. 
The Plan says the cost share is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for vision care and 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $15 copay for an intravitreal injection of a pharmacologic agent and 20% 
coinsurance for aflibercept injection. The aflibercept injection falls within the Medicare Part B prescription 
drugs benefit category and intravitreal injection of a pharmacologic agent falls 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 coinsurance for aflibercept injection (J0178) and copayment 
for intravitreal injection of a pharmacologic agent (67028).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physician services you received while you 
were an inpatient in the hospital from June 4, 2020, to June 5, 2020. 
 
You asked the Plan to waive the coinsurance for the physician services. You say that you should only have to 
pay your inpatient copayment and any additional cost sharing should be waived. The Plan denied your request. 
The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for physician services while you're an inpatient in a hospital.  
 
You have been asked to pay 20% coinsurance for the physician 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 coinsurance for physician services you received while you were an inpatient in the hospital from June 4, 
2020, to June 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the EMS 
on April 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 April 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 by the EMS on April 11, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for ultrasound services (CPT 76604 and CPT 76705) provided to the 
enrollee on February 2, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 76705: 
ultrasound, abdominal, real time with image documentation; limited 
 
CPT 76604: 
ultrasound, chest, real time with image documentation 
 
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 reviewers say that the 
services at issue in this case were supported by the medical records. Our physician reviewer found fast 
ultrasound scans are a mainstay in the ED setting for patients with trauma. The cardiac, lungs, pleura were 
evaluated on the chest ultrasound (76604) and the abdominal organs and presence of fluid were evaluated on 
the limited abdomen (76705). The documentation was appropriate and both claims should be paid. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
ultrasound services (CPT 76604 and CPT 76705) provided to the enrollee on February 2, 2020.  
 
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 pay fora Bevacizumab injection provided to the enrollee on May 2, 2020.You asked the Plan to pay forthe injection. You say that this should be paid for.The Plan denied your request. The Plan says there is a more appropriate code to use in this case.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 HCPCS code J9035 is "injection, bevacizumab, 10mg."We asked our coding 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found that HCPCS J7999 is the more appropriate code to report for the use of bevacizumab for ophthalmologic procedures. Therefore, it is inappropriate to bill HCPCS code J9035 to represent this service.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plan does not have to pay fora Bevacizumab injection provided to the enrollee on May 2, 2020.