Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on April 20, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for the DME provided on April 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided March 2, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you are requesting reconsideration 
for reprocessing of the claim for payment. The Plan denied your request. The Plan says the claim was not billed 
in accordance with CMS guidelines. 
 
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 find that CPT code is not supported in the medical record. Specifically, according to CMS Chapter 15 
(section 100.5.1 is for outpatient hospital services) explains in detail how to bill for reimbursement. A corrected 
claim must be resubmitted. Based on this information, we decided that Medicare rules for coverage of the 
outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital services provided March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 18, 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 19366 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 19366 is breast reconstruction with other technique. 
 
We find that CPT code 19366 is not supported in the medical record. Specifically, there is no documentation of 
a breast reconstruction with other technique. 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 
surgical services rendered on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids rendered on October 21, 2019. 
 
You asked the Plan to pay for these services. You say that the provider told you that they accepted all 
insurance. The Plan denied your request. The Plan says the services are not covered. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only from a participating provider. 
 
We looked at the file and the Plan's rules. The file shows that you did not purchase hearing aids from a 
participating provider. Based on this information, we decided that 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 hearing aids rendered on 
October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on July 7, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were never told that you would have to 
pay for the panoramic x-ray. The Plan denied your request. The Plan says this service is not a covered benefit. 
The Plan also says that it was confirmed that you signed a financial agreement with the provider's office, prior 
to this service being rendered, which indicates that you are responsible for any non-covered charges. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the periodic comprehensive preventive 
medicine examination (99397), and the office visit (99212) provided on June 3, 2020. 
 
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 the copayment was applied correctly to the 
services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for consultation, diagnosis, and treatment by a specialty physician. 
 
You have been asked to pay a $20 copayment for the services provided by a specialty physician. This 
copayment has been applied as you addressed other medical issues with your physician in addition to your 
annual physical. It is appropriate for the provider to bill for an office visit in addition to the annual  
Obstetrics and Gynecology (OBGYN) visit as there was a discussion with the physician and a plan to correct a 
medical issue. 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 periodic comprehensive preventive 
medicine examination (99397), and the office visit (99212) provided on June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniSeq Advance panel testing rendered on March 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genomic sequence analysis panel testing is covered for 
NSCLC.  
 
We looked at the file and Medicare rules. The file shows that the testing was performed for a diagnosis of 
prostate cancer, which is not a diagnosis for which this testing is covered by Medicare. 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 OmniSeq Advance panel testing rendered on March 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 6, 2020, to 
March 7, 2020. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not covered under Part B of Original Medicare. 
 
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 pay for the self-administered drugs 
provided from March 6, 2020, to March 7, 2020.  
 
Benefits for the self-administered drugs 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 radiation therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found it is safe to say that intensity modulated radiation therapy (IMRT) is not experimental, but 
rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose 
distribution in select patients. IMRT can be considered medically necessary when a clinically meaningful 
reduction in normal tissue dose exposure can be achieved. For this case, IMRT would be furnished in 
accordance with accepted standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy.  
 
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 waive the copayment for deluxe frames (V2020) progressive lenses 
(V2781) purchased May 21, 2020. 
 
You asked the Plan to waive the copayment for the frames and lenses. You say that you wish to appeal a claim 
for payment for glasses that were purchased on 5/21/2020. You also paid $148 out of pocket. The Plan denied 
your request. The Plan says the claim was processed with the correct copayment applied per the plan benefits. 
 
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 any 
amount over the $200 eyewear benefit for Vision care.  
 
You have been asked to pay $148 for the frames and lenses. The provider submitted total charge of $385. The 
$200 eyewear benefit was applied as well as a 20% discount. Therefore, the remaining $148 is your 
responsibility. The frames and lenses 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 copayment for deluxe frames (V2020) progressive lenses (V2781) purchased May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump 
(E2402). 
 
You asked the Plan to pre-approve an NPWT pump. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an NPWT pump will be denied as not reasonable and 
necessary under certain circumstances. 
 
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 an NPWT pump. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the enrollee continues to meet the coverage criteria. The NPWT pump has been used 
for greater than four months; continued use of the NPWT pump beyond four months regardless of the wound's 
condition is not authorized in the Local Coverage Determination (LCD): Negative Pressure Wound Therapy 
Pumps (L33821). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an NPWT pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a negative pressure wound therapy (NPWT) pump (E2402).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug infusion you 
received on April 8, 2020. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B drug infusion. You say that you disagree 
with the cost of these services and you feel the costs are not your responsibility. The Plan denied your request. 
The Plan says you were charged this amount correctly. You were only charged coinsurance up to your $400 
out-of-pocket maximum. 
 
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 Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Medicare Part B drug infusion up to your $400 annual 
out-of-pocket maximum. 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 Medicare Part B drug 
infusion you received on April 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac joint injection. 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 sacroiliac joint injection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the notes show that the enrollee has failed conservative therapy including physical 
therapy for over 12 weeks, massage therapy, chiropractics, home exercise, nonsteroidal anti-inflammatory 
drugs (NSAID's) for over 12 weeks and opioids. Imaging studies have been performed. A physical exam is 
documented. The prescriber stated that Patrick's Maneuver, Gaenslen's Test and Pelvic compression test on the 
left side were all positive. The provided medical records document that the requested services are medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have been met. Therefore, we decided that the Plan has 
to pre-approve sacroiliac joint injection.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for OB/GYN services (HCPCS J7307) provided to the enrollee 
on September 4, 2019. 
 
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 is an invalid procedure code for this service. 
 
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 J7307 is "Etonogestrel (contraceptive) implant 
system, including implant and supplies." 
 
We find that HCPCS code J7307 is not supported in the medical record. Specifically, this code 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 OB/GYN services (HCPCS 
J7307) provided to the enrollee on September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 30, 2019 to August 1, 
2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier Emergency and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided July 30, 2019 to August 1, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays and 
prophylaxis provided on March 16, 2020.  
 
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays and prophylaxis. You say that 
you were under the impression the visit would have a $0 copayment. You say that the plan should pay 100% of 
your preventive care. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for the periodic oral evaluation, bitewing x-rays and prophylaxis when received from an out-
of-network provider. You are responsible for the remaining amount. Therefore, we decided that the Plan does 
not have to pay more for the periodic oral evaluation, bitewing x-rays and prophylaxis provided on March 16, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional month rental beyond the two months 
approved by the Plan.  
 
You asked the Plan to pre-approve three-month rental. You say that three months rental is medically necessary. 
The Plan denied your request. The Plan says while two months were approved, the third month was denied as 
not being medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a total of 
three-months rental. Our reviewer says that Medicare coverage criteria are not met for 3 months rental total 
were not met. Our physician reviewer found the plan is correct in this case. The documentation in the case file 
does not support that an additional month of Dynasplint rental is medically reasonable and necessary, as 
documentation of use and response is insufficient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of three-month rental. Therefore, we decided that the Plan does not have to pre-approve three-month rental for a Dynasplint stretching device for the enrollee.