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

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation, complete series of 
intraoral x-rays, prophylaxis, and preventive procedure provided on September 21, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation, complete series of intraoral x-rays, 
prophylaxis, and preventive procedure. You say that you contacted the Plan and were told that this treating 
provider was in-network. The Plan denied your request. The Plan says the treating provider has opted out of 
Medicare. The Plan also says that neither you nor the provider contacted the Plan prior to the date of service to 
verify the provider's participation status. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation, complete series of intraoral x-rays, prophylaxis, and preventive 
procedure provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on May 23, 2020, through 
June 23, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because this 
providers care gave you substantial relief. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient services provided on May 23, 2020, through June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the walker purchased on August 20, 2020 from a 
non-certified supplier. 
 
You asked the Plan to reimburse you for the folding wheeled walker. You say that you want the Plan to 
reimburse you for the walker. The Plan denied your request. The Plan says you obtained durable medical 
equipment from a provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items provided directly by a provider who is not eligible to take Medicare payment.    
 
The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided 
that the Plan does not have to reimburse you for the walker purchased on August 20, 2020 from a non-certified 
supplier.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection panel testing provided on July 24, 
2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that infectious agent detection testing panel 87631 
must be ordered by an infectious disease specialist when billed in a place of service other than urgent care, 
inpatient hospital, or emergency room.  
 
We looked at the file and Medicare rules. The ordering physician for this testing was not an infectious disease 
specialist. This testing was not performed in a place of service for which this test may be ordered by a provider 
of any specialty. Based on this information, we decided that Medicare rules for coverage of lab test have not 
been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection panel testing 
provided on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from June 25, 2020 to 
July 30, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from June 25, 2020 to July 30, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires, (apnea monitor), per pair (A4557) provided 
September 20, 2020. 
 
You asked the Plan to pay for the lead wires. You say that per CMS LCD L33802, A4557 is not inclusive to 
A4595 and is separately reimbursable. Please reconsider for payment or provide documentation supporting 
your decision. The Plan denied your request. The Plan says this service is not allowed because it is included in 
another service provided at the same time or within a one year period. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead 
wires, (apnea monitor), per pair (A4557) provided September 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physician service on July 22, 2020. 
 
You asked the Plan to waive the copayment for the physician service. You say that there should be no 
copayment for a Wellness Visit. The Plan denied your request. The Plan says the medical records document 
that you had a diagnosis which is outside of the Annual Wellness Visit and allows the provider to bill for a 
separate exam. 
 
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 for Physician Services.  
 
You have been asked to pay a $35 copayment for the physician service. The physician service falls within the 
Physician Services benefit category. The record supports the billed charges. 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 physician service on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. 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 the 
member's primary care physician did not refer 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 physician services provided by an 
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid check you received on September 18, 2020. 
 
You asked the Plan to pay for the hearing aid check. The Plan denied your request. The Plan says this is not a 
TruHearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids and hearing aid services only when provided by a TruHearing provider.  
 
We looked at the file and the Plan's rules. The Plan?s hearing aid benefit only covers services provided by a 
TruHearing provider. The services you received on September 18, 2020, were not provided by a TruHearing 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid check you received 
on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92004) provided on 
July 19, 2018. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you should not be charged 
for this appointment. The Plan denied your request. The Plan says the copayment has processed 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 $50 
copayment for Medicare-covered eye exam.  
 
You have been asked to pay a cost share of $40, which is less than the required $50 copayment for the medical 
eye exam. The service provided falls within the Medicare-covered eye exam benefit category. This 
appointment was not for a routine vision exam but was to diagnose a specific medical problem with your eyes. 
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 medical eye exam (92004) provided on July 19, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Glossectomy procedure provided on March 20, 2020. 
 
You asked the Plan to pay for the Glossectomy procedure. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for 
inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or 
hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers.  
 
This was an inpatient service. Payment for this service would have been included under the global facility 
claim. Payment to you for this service is the responsibility of the facility or hospital.  Based on this 
information, we decided that Medicare rules for coverage of the Glossectomy procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for the Glossectomy procedure provided on March 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that the provider should not be penalized for the 
hospital not acquiring prior authorization. The Plan denied your request. The Plan says prior authorization was 
not obtained. The Plan says that the referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician services provided on February 25, 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 pharmacogenetic testing provided on August 15, 2020. 
 
You asked the Plan to pay for the testing. You say that the testing was medically necessary and requested by 
the member's physician. The Plan denied your request. The Plan says a panel constitutes a single procedural 
service, so one HCPCS code must be submitted for the panel. 
 
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, the testing, was requested solely for screening purposes. The documentation 
does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug 
reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need 
for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for the 
pharmacogenetic testing provided on August 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on July 17, 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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on July 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the services were not 
urgent, emergent or approved in advance. 
 
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 medical services provided on August 24, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99285) 
provided August 6, 2020 to August 9, 2020. 
 
You asked the Plan to waive the copayment for the emergency visit. You say that the assertions made for the 
denial were not accurate. The Plan denied your request. The Plan says this claim was processed correctly and 
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 $90 
copayment for out of network emergency room services.  
 
You have been asked to pay $90 copayment for the emergency visit. The emergency visit falls within the 
Emergency 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 emergency 
department visit (99285) provided August 6, 2020 to August 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on August 24, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. 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 
the referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 durable medical equipment provided on August 
24, 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 massage therapy services (97124) provided July 9, 2020 to 
August 27, 2020. 
 
You asked the Plan to pay for the massage therapy services. You say that here is the authorization from your 
doctor stating that it is medically necessary for you to receive weekly massages. The Plan denied your request. 
The Plan says this service is not covered by the plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy services (97124) provided July 9, 2020 to 
August 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) 
test provided on August 10, 2020. 
 
You asked the Plan to waive the copayment for TTE test. You say that you cannot understand the difference in 
cost-sharing between this and a previous test. The Plan denied your request. The Plan says the copayment 
amount you are being charged 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 $160 
copayment for in-network TTE test.  
 
You have been asked to pay $160 copayment for TTE test. TTE test 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 transthoracic echocardiography (TTE) test provided on August 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (S9500 and S9501) provided 
to the enrollee from May 14, 2020 to May 20, 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 the current Physician Fee Schedule does not price the requested codes, as they are no longer 
covered by Medicare. 
 
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: 
 
S9500: 
 
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative 
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs 
and nursing visits coded separately), per diem 
 
S9501: 
 
Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative 
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs 
and nursing visits coded separately), per diem 
 
We find that HCPCS codes S9500 and S9501 is not supported in the medical record. Specifically, the codes has 
a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not 
valid for Medicare purposes. 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 home infusion therapy 
services (S9500 and S9501) provided to the enrollee from May 14, 2020 to May 20, 2020.