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

 
We decided that the Plan has to pay for the negative pressure wound therapy (NPWT) electrical pump, 
stationary or portable rental (E2402) provided December 1, 2019 to December 24, 2019. 
 
You asked the Plan to pay for NPWT electrical pump. You say that per contract there are no caps or limits 
exceeding regarding authorization. Please reprocess the claim on payments due. The Plan denied your request. 
The Plan says that the maximum number of rentals have already been paid. Based on Medicare guidelines, 
payment for rental items may not exceed a period of continuous use longer than 13 months. 
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan has not provided information to support their reason for denial. The plan 
denied that the maximum number of rentals have already been paid out. The plan has not provided any 
documentation that payments were made for this device. The plan used the general rule for capped rental items 
which says payment for rental items may not exceed a period of continuous use longer than 13 months.  The 
LCD rule for this device says after four months have passed each month needs to be approved individually with 
the doctor saying that healing is continuing and would likely stop without continued use of the pump. 
Therefore, we decided that the Plan has to pay for the negative pressure wound therapy (NPWT) electrical 
pump, stationary or portable rental (E2402) provided December 1, 2019 to December 24, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 27, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. 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 emergency care on the date 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 $90 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on February 27, 2020. You have been asked to pay a $90 copayment for the emergency room visit. 
The emergency room 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 room visit provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from January 27, 2020 to 
January 28, 2020. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an inpatient admission provided from January 27, 2020 to 
January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating hospital on February 17, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not agree with 
this copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for outpatient hospital observation.  
 
You have been asked to pay $102.42 which is less than your copayment amount of $375 for outpatient hospital 
services. The correct copayment has been applied to the services that were provided. Outpatient hospital 
services fall within the outpatient hospital observation 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 outpatient hospital services provided by a participating hospital on February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and intraoral 
x-rays provided on October 2, 2019. 
 
You asked the Plan to pay for the prophylaxis, comprehensive oral evaluation and intraoral x-rays. You say that 
you selected the dentist from the catalog of approved network providers. You say that the provider and 
insurance should resolve the matter. The Plan denied your request. The Plan says out-of-network dental 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis, 
comprehensive oral evaluation and intraoral x-rays provided on October 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ALS emergency ambulance service (A0427) and ground 
mileage (A0425) provided February 26, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the claim was denied as other diagnosis 
codes being missing/incomplete/invalid. After reviewing the codes it was determined that the diagnosis codes 
being used are correct. The Plan denied your request. The Plan says the billed codes were denied because the 
diagnosis codes associated to it are mismatched. There is an appropriate diagnosis code. 
 
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 billed codes A0427 and A0425 were denied because the diagnosis codes (R22.41 and R22.42) 
associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting. According 
to ICD-10-CM Manual, there is an appropriate diagnosis code for bilateral condition i.e., R22.43 (Localized 
swelling, mass and lump, lower limb, bilateral). Based on this information, we decided that Medicare rules for 
coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay 
for the ALS emergency ambulance service (A0427) and ground mileage (A0425) provided February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Acetaminophen - Codeine #3 tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Acetaminophen - Codeine 
#3 tablet for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on October 14, 
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 the diagnosis code has not been coded to the full number of characters. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate 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 
services at issue in this case were not reported correctly. Our physician reviewer found based on the medical 
records provided, the listed ICD-10 code of M50.82 is not sufficiently specific for billing and requires a 6th 
digit for validity. 
 
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 neurology services provided to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 2, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the appointment was not necessary. 
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 $50 
copayment for services obtained from an in-network specialist.  
 
Review of the file shows that you received specialist services on March 2, 2020. You have been asked to pay a 
$50 copayment for these services. These services fall within the services obtained from an in-network specialist 
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 specialist services rendered 
on March 2, 2020.  
 
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 7, 2019. 
 
You asked the Plan to pay for the laboratory 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on February 15, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you have never been charged in the past 
and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $100 
copayment for an MRI provided by a freestanding provider.  
 
You have been asked to pay a $100 copayment for an MRI. An MRI 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 
an MRI provided on February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 8, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. 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 the 
drug testing services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee January 28, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 services at issue in this appeal. 
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for physician services provided to the 
enrollee January 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43235). 
 
You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that a repeat endoscopy is 
recommended even in the absence of symptoms to confirm the diagnosis. The Plan denied your request. The 
Plan says a repeat procedure is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that sequential or periodic diagnostic upper GI 
endoscopy may be indicated for an appropriate number of procedures for active or symptomatic conditions as 
listed above. 
 
We looked at the file and Medicare rules. The record does not indicate the enrollee has any of the indications 
listed above. The records show that the enrollee is asymptomatic and currently well-managed. Based on this 
information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy 
(43235).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided November 25, 2019 to December 5, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that at the time of these appointments you were 
recovering from 2 broken legs with no weight bearing on the legs. You were bed confined for 3 months and 
stretcher/ambulance transport was your only option. The Plan denied your request. The Plan says transportation 
to a physician office is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and 
ground mileage (A0425) provided November 25, 2019 to December 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 23, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says there is no authorization on file for services 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calquence.

You asked the Plan to pre-approve the Calquence. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B for the member's condition.

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 Calquence. 

Benefits for the Calquence 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 19, 2019. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing services provided on June 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on February 24, 2020. 
 
You asked the Plan to pay for the osseous surgery (D4261). You say that the treatment was medically 
necessary. You say that the Plan covers dental work at 50%. The Plan denied your request. The Plan says the 
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 pay for the 
osseous surgery (D4261) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased February 27, 2020 from an out of 
network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you need clarification on why this is being denied. 
You have submitted previous claims with the same plan and have been paid. If you get paid on one retiree with 
this plan why not on this one. The Plan denied your request. The Plan says hearing aids purchased from an out 
of network provider is 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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased February 27, 2020 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for single vision lenses (V2100) and sales tax (S9999) provided 
March 25, 2020. 
 
You asked the Plan to pay for the vision services. You say that the booklet that you were sent for 2020 changes 
states that eyewear is covered and nothing about using an in network provider. The Plan denied your request. 
The Plan says vision services are not covered when rendered by an out of network provider. Sales tax is non-
covered service per Medicare guidelines. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. Vision services must be provided by an in-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for single vision lenses (V2100) and sales tax (S9999) 
provided March 25, 2020.