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

 
We decided that the Plan does not have to reimburse you for the immediate upper denture and the immediate 
lower denture provided on August 12, 2020. 
 
You asked the Plan to reimburse you for the dental items. You say that you needed dentures and extractions. 
You say that you had an allergic reaction to the local anesthesia. You say that you had to go to a different 
location for the services. You say that you had to pay upfront for the services. You also say that you cannot 
afford to pay for these services. The Plan denied your request. The Plan says there is a $1,500 allowance for 
covered dental services. The Plan also says that the dental allowance has been exhausted. 
 
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 $1,500 dental allowance has been 
exhausted. The record shows that the Plan paid $108 for services that you received on June 18, 2020 and 
$1,392 towards dental services that you received on August 12, 2020, thus exhausting the dental allowance. 
After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided 
that the Plan does not have to reimburse you for the immediate upper denture and the immediate lower denture 
provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cancer predictive screening testing provided on 
March 27, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this 
testing is not a Medicare benefit for the diagnoses listed and was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
hereditary cancer predictive screening testing provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a walk-in bathtub purchased on August 6, 2020. 
 
You asked the Plan to reimburse you for a walk-in bathtub. You say that the walk-in bathtub is for safety 
because you are unsteady due to multiple medical problems. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that walk-in bathtubs are not covered because they 
are not primarily medical in nature.  
 
While a walk-in bathtub may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to reimburse you for a walk-in bathtub purchased on 
August 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept (A0432) provided on June 22, 2020. 
 
You asked the Plan to pay for paramedic intercept. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept (A0432) provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on July 27, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are requesting the claim to be reconsidered with 
the medical notes. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 had network providers 
available who could have provided 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 outpatient office visit (99205) provided on 
July 27, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olmesartan Medoxomil Tab 20mg 
 
You asked the Plan to pre-approve Olmesartan Medoxomil. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Olmesartan Medoxomil Tab 
20mg  
 
Benefits for Olmesartan Medoxomil may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature.. You say that you would like 
reconsideration because the elevator seat is necessary due to the member's upper body deficits. The Plan denied 
your request. The Plan says the item requested does not meet durable medical equipment coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that a power seat elevation feature is non-covered because it is not 
primarily medical in nature. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist x-ray rendered on June 26, 2020. 
 
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. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the diagnosis code was not billed ot the highest 
level of specificity. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the wrist x-ray rendered on 
June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation of outpatient visit (99202) radiologic 
examination, cervical spine (72040) radiologic examination, lumbosacral spine (72100) provided August 19, 
2020. 
 
You asked the Plan to pay for the office visit and x-ray services. You say that you feel unduly prejudiced 
against when Medicare covers up to 12 visits for medically needed chiropractic services. You are making an 
appeal for redetermination. The Plan denied your request. The Plan says these services are not covered when 
provided by a chiropractor. 
 
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 evaluation of outpatient visit (99202) radiologic examination, cervical spine 
(72040) radiologic examination, lumbosacral spine (72100) provided August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 7, 2020. 
 
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 July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2020. 
 
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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the place of service on the CMS-1500 form 
line 24B must reflect the location of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of 
Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face 
service. 
 
We find that these services are not supported in the record. Specifically, the billed POS code does not reflect 
the actual setting where the specimen was obtained. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray rendered on September 24, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services should be part of the 
office visit copayment. The Plan denied your request. The Plan says the copayment 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 $30 
copayment for each Medicare-covered x-ray service.  
 
Review of the file shows that you received an x-ray on September 24, 2020. You have been asked to pay a $30 
copayment for these services. These services fall within the Medicare-covered x-ray service 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 x-ray rendered on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99203) x-ray, spine; thoracic (72070) 
x-ray, spine, lumbosacral (72100) 
 
You asked the Plan to pay for the office visit and x-rays. You say that you are asking for an appeal because the 
services was ok'd before you went. The Plan denied your request. The Plan says these services are not covered 
when performed by a chiropractor. 
 
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 outpatient office visit (99203) x-ray, spine; thoracic (72070) x-ray, spine, 
lumbosacral (72100)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 27, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on June 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided on June 3, 2020 to 
July 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that these services were medically necessary 
and provided in good faith. The Plan denied your request. The Plan says these services were not authorized. 
 
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 had network providers 
available who could have provided 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 nursing facility care (99308) provided on June 
3, 2020 to July 29, 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 an office visit and lab work provided on October 7, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-
network providers available for these 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 an office visit and lab work provided on October 
7, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 9, 2020. 
 
You asked the Plan to pay for dental services. You say that you searched for an in-network provider. You say 
that the office gave you a provider that is out-of-network. The Plan denied your request. The Plan says out-of-
network services 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, out-of-network services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services 
provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered on October 22, 
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 procedure code 14301 is 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 code 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
We find that CPT code 14301 is not supported in the medical record. Specifically, there is no documentation of 
adjacent tissue transfer or rearrangement. The records show that a muscle, myocutaneous, or fasciocutaneous 
flap was performed and there is a more appropriate code for these services. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient surgical services rendered on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
July 30, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the charges are not logical. The 
Plan denied your request. The Plan says the copayment 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 $150 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
Review of the file shows that you received outpatient surgical services to your eye on July 30, 2020. You have 
been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered 
surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other 
facility charges and physician or surgical charges 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 outpatient surgical services rendered on July 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were not told there would 
be a charge. You say that you wouldn't have had so many visits if you knew of the cost at the time of service. 
The Plan denied your request. The Plan says the copayments 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 $35 
copayment per therapy type, per provider, per day for physical and speech services. 
 
You have been asked to pay a $35 copayment for each physical therapy visit. The total amount you owe is 
$420 ($35/visit x 12 visits = $420). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided.
Appeal type: Imaging
Decision: Unfavorable


We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71250) performed on September 8, 2020.

You asked the Plan to waive the copayment for a CT scan of the thorax. You say that you do not believe you should be responsible for such a high copayment. The Plan denied your request. The Plan says the correct copayment was 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including X-rays. 

You have been asked to pay a $125 copayment for a CT scan of the thorax. A CT scan of the thorax falls 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 a CT scan of the thorax (71250) performed on September 8, 2020.