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

 
We decided that the Plan does not have to pay an additional amount for hearing aids provided on June 5, 2020. 
 
You asked the Plan to pay an additional amount for the hearing aids. You say that you were told that the Plan 
would pay $150 per ear for hearing aids. The Plan denied your request. The Plan says that the Plan paid $150 
towards the claim, leaving you a responsibility of $1,040. Your claim processed correctly; therefore, no 
changes can be made to your copayment. 
 
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 file and the Plan's rules. The file shows that the Plan paid the correct amount of $150 for the 
hearing aids based on the Plan?s hearing aid benefit. Therefore, we decided that the Plan does not have to pay 
an additional amount for hearing aids provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelocalized delivery of antimicrobial agents on tooth #31 (D4381).You asked the Plan to pre-approvelocalized delivery of antimicrobial agents on tooth #31. You say that the service is necessary.The Plan denied your request. ThePlan says the requested service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvelocalized delivery of antimicrobialagents on tooth #31 (D4381).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided from August 18, 2019, to August 19, 
2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that since you 
have an HMO plan, and you were seen by an out-of-network provider, you will be responsible for charges 
above the maximum allowable fee. 
 
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 documentation does that that if you visit an out-of-network provider, you will be responsible for any 
charges above the Plan's maximum allowable fee. However, it goes on to say there are exceptions to this rule 
that may apply if you live in. The Plan has not provided further documentation to show that the 
exceptions to this rule have not been met. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the medical services provided from August 18, 2019, to August 19, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a parotid tumor or parotid gland; total, with 
dissection and preservation of the facial nerve (42420) provided on March 16, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this procedure code is not supported by the 
medical records submitted. The operative report did not include documentation of a total excision of a parotid 
tumor or parotid gland, with dissection and preservation of the facial nerve; therefore, this code cannot be 
substantiated. 
 
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 42420 is the excision of a parotid tumor or parotid gland; 
total, with dissection and preservation of the facial nerve. 
 
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 this service. Our reviewer says that this code 
does not meet criteria for coverage. Our physician reviewer found that the medical records provided only note 
that the parotid tail was removed, which does not meet definition criteria of CPT code 42420; therefore, 
procedure code 42420 LT GC cannot be verified.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the excision of a parotid tumor or parotid gland; total, with dissection and preservation of the 
facial nerve (42420) provided on March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 78815) provided to the enrollee on 
August 11, 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 this was billed with a secondary only diagnosis code as the primary, first-listed, or principal 
diagnosis. 
 
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 78815 is "Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging." 
 
This code cannot be reported with a secondary-only diagnosis as the primary diagnosis code. 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 radiology services (CPT 78815) provided to the enrollee on 
August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a balloon dilation of leg arteries and related services and supplies. You say that 
these services were medically necessary. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
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 medical services provided on August 5, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 13, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that there was no actual examination 
provided. You say that you shouldn't be billed. 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 $50 
copayment per specialist office visit.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctors office visits" 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 office visit provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from September 14, 2019 to September 27, 2019. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says 
that the correct copayment has applied per your contract with the Plan. 
 
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 $0 
copayment per day for days 1-20 and a $160 copayment per day for days 21-46 for Skilled Nursing Facility 
(SNF) Care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received SNF care from 
August 10, 2019 to August 22, 2019. You have been asked to pay a $0 copayment per day for days 1-12 for the 
SNF care. The file shows that you received SNF care from September 14, 2019 to September 27, 2019. You 
have been asked to pay a $0 copayment per day for days 13-20 and a $160 copayment per day for days 21-25, 
totaling $800. The SNF care falls within the Skilled Nursing Facility (SNF) 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 copayment for the skilled nursing facility (SNF) care provided from September 14, 
2019 to September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bypass graft, with vein; illofemoral (CPT Code 35565 62 78 
RT) provided. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 services. Our reviewer says that the 
billed code is not supported in the medical records. Our physician reviewer found that the code used, 35565, 
only applies for an ileofemoral bypass performed with autologous vein. An ileofemoral bypass performed with 
any other conduit, be it prosthetic or, as in this case, cryopreserved femoral vein uses code 35665. Criteria for 
coverage of code 35565-62-RT are therefore, not met 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for bypass graft, with vein; iliofemoral (CPT Code 35565 62 78 RT) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (97032) provided on July 20, 2020. 
 
You asked the Plan to pay for the electrical stimulation. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit 
under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (97032) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab and leuprolide acetate 
injections provided on January 23, 2020 and May 18, 2020. 
 
You asked the Plan to waive the coinsurance for the denosumab and leuprolide acetate injections. You say that 
your insurance should cover some things. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Part B-covered chemotherapy drugs and other Part B covered drugs. 
 
You have been asked to pay a total of $1,206.14 for the denosumab and leuprolide acetate injections.  
 
Date of Service Service Allowed 
Amount 
Coinsurance Member Liability 
January 23, 2020 Denosumab Injection $2,313.60 20% $462.72 
January 23, 2020 Leuprolide Acetate Injection $690.21 20% $138.04 
May 18, 2020 Denosumab Injection $2,320.80 20% $464.16 
May 18, 2020 Leuprolide Acetate Injection $706.11 20% $141.22 
TOTAL:    $1,206.14 
 
The denosumab and leuprolide acetate injections fall within the "Medicare Part B prescription drugs" 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 denosumab and leuprolide acetate 
injections provided on January 23, 2020 and May 18, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the inpatient skilled nursing facility (SNF) care 
provided from November 1, 2019, through November 6, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that you must pay $0 per day, for days 1-20; $167.50 per day, for days 21-100 for 
each skilled nursing facility (SNF) stay.  
 
The Plan says you must pay $837.50 ($167.50 copayment x 5 days) for the inpatient skilled nursing facility 
care provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment per 
day, for days 1-20, for each inpatient skilled nursing facility admission. Therefore, we decided that the Plan has 
to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from November 1, 2019, 
through November 6, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove power wheelchair accessories (E2311, E2377, E2313). 
 
 
 
You asked the Plan to preapprove power wheelchair accessories. You say that these items should also be 
covered. The Plan denied your request. The Plan says they believe the power wheelchair is necessary and 
overturned it, the plan holds that the accessories (E2311, E2377, E2313) exceed medical necessity. 
 
The Plan must follow Medicare rules. The rules say that coverage is granted when services meet but do not 
exceed the beneficiary?s need. We found that there is not medical need to control these power options through 
the joystick.  Therefore, we decided that the Plan does not have to preapprove power wheelchair accessories 
(E2311, E2377, E2313).
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 you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the medical records provided 
do not document that the enrollee meets Medicare criteria. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical 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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 medical services provided on August 13, 2020 by an out of network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided. 
 
You asked the Plan to pay for the services provided. You say that the test was medically necessary in 
determining the best course of treatment. The Plan denied your request. The Plan says the test has not been 
shown to result in improved outcomes. 
 
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 provided medical records do not show that the results of the 
testing would be used to determine a specific treatment strategy. This testing has not been shown to result in 
improved outcomes for Medicare beneficiaries and thus is not medically necessary. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from June 9, 2020, to 
October 6, 2020. 
 
You asked the Plan to pay for the services provided. You say that your once a month visit is not considered 
maintenance. The Plan denied your request. The Plan says maintenance chiropractic services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the file, and Medicare rules. The file shows that you received chiropractic treatments on June 9 
and 19, 2020. Your provider agreed to write off the charges, with no cost share liability to you. You also 
received chiropractic treatments on August 18, 2020, September 15, 2020, and October 6, 2020. The 
documentation from the provider?s office indicate the services were maintenance treatments. There are 
insufficient records to show that the services were provided to correct subluxation of the spine. Medicare also 
does not cover chiropractic treatments to extraspinal regions. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the chiropractic services provided from June 9, 2020, to October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's level of function is poor at this time. 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does require physical therapy and occupational therapy services but based on the medical records provided the 
enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the 
enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility due to weakness, confusion and poor endurance. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.