Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation service (A0428) and the 
ambulance mileage (A0425) provided on September 10, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that Original Medicare is responsible for 
payment of these services as the member was enrolled in hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance transportation service (A0428) and the 
ambulance mileage (A0425) provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on July 2, 2020. 
 
You asked the Plan to pay for the CGP testing. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on January 29, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1832RT). You say that the orthosis at issue is different than 
the enrollee's other orthosis. The Plan denied your request. The Plan says the enrollee has the same orthosis 
still under reasonable useful lifetime. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The enrollee's orthosis is still within the 5-year RUL and the documentation submitted does not show that the 
orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on the records provided, there is no indication the orthoses 
provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for 
orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the knee 
orthosis provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-invasive extremity arterial study 
you had. 
 
You asked the Plan to waive the copayment for the non-invasive extremity arterial study. You say that you 
don't understand why you were charged this amount. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that because the allowed amount for this test ($96.53) is less 
than your copayment obligation, you are responsible for the full 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 each radiological diagnostic service.  
 
You have been asked to pay a $100 copayment for the non-invasive extremity arterial study. The non-invasive 
extremity arterial study falls within the radiological diagnostic 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 non-invasive extremity arterial study you had.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on May 28, 2020. 
 
 
 
You asked the Plan to pay for the electrocardiogram (93010). You say that the electrocardiogram was 
necessary as part of the enrollee's treatment. The Plan denied your request. The Plan says the electrocardiogram 
was not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The diagnosis code does not support medical necessity for this test. 
Based on this information, we decided that Medicare rules for coverage of the electrocardiogram (93010) have 
not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on 
May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Synvisc injection (J7325) received on 
April 24, 2020. 
 
You asked the Plan to waive the coinsurance for a Synvisc injection. You say that you had the injection with 
prior authorization and were not aware of the 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 20% 
coinsurance for Medicare Part B covered drugs.  
 
You have been asked to pay $105.60, or 20% of the Plan-allowed amount of $528, for a Synvisc injection. A 
Synvisc injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a Synvisc injection (J7325) received on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 12, 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 screening tests are 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 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 March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601, E1399) purchased from CPAP.com. 
 
You asked the Plan to pay for a CPAP device. You say that this is a covered benefit. The Plan denied your 
request. The Plan says the supplier for the items at issue is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The supplier you purchased the items at issue from is not enrolled in 
the Medicare program. Based on this information, we decided that Medicare rules for coverage of a CPAP 
device have not been met. Therefore, we decided that the Plan does not have to pay for a continuous positive 
airway pressure (CPAP) device (E0601, E1399) purchased from CPAP.com.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided. 
 
You asked the Plan to pay for the CGP testing. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forskin protection and positioning wheelchair seat cushion (E2607) provided May 18, 2020.You asked the Plan to pay forthe wheelchair seat cushion. You say that you have received authorization approval. This is the first timeyou are billing for this item. Please review the attached documentation and reconsider for payment.The Plan denied your request. The Plan says service exceeds recommended frequency.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that C. Craver had E2607 at the time the wheelchair seat cushion was received. E2607 serves the same purpose as the wheelchair seat cushion that was received on August 10, 2017. There is no evidence that the seat cushion that the enrollee received in 2017 was lost, stolen, or destroyed. Therefore, we decided that the Plan does not have to pay forskin protection and positioning wheelchair seat cushion (E2607) provided May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on April 30, 2019 by an OON 
provider. 
 
You asked the Plan to pay for the prophylaxis. You say that neither you nor the provider were aware that the 
provider was non-participating. The Plan denied your request. The Plan says the service was rendered by a non-
participating provider. 
 
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, you are responsible for a 50% 
coinsurance and the difference between the billed amount and allowed amount when the service is received 
OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on April 30, 2019 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Insitu hybridization services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the Insitu hybridization services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Insitu hybridization services provided by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you consider this a medical condition. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1851, L2397) provided June 10, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says Medicare rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2397) 
provided June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020 by an out of 
network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 referring provider is not a 
network provider with the Plan. The Plan has network providers available who can provide the items/services 
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the medical services provided on April 16, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for physical therapy services provided on July 
20, 2020. 
 
You asked the Plan to reduce the deductible for physical therapy services. You say that you were led to believe 
payments for this service were $35 per session. You say that your bill should reflect this rate. The Plan denied 
your request. The Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services. Outpatient therapy is not excluded from the deductible. 
 
The item or service you asked the Plan to reduce the deductible for falls within the "Outpatient rehabilitation 
services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$750 deductible applies to outpatient therapy. This cost sharing is a contractual obligation that had not been 
met at the time physical therapy services were received on July 20, 2020. Therefore, we decided that the Plan 
does not have to reduce the deductible for physical therapy services provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Secretin injection (J2850) provided. 
 
You asked the Plan to waive the coinsurance for the Secretin injection. You say that you were not notified of 
the coinsurance charge for the drug before the procedure. The Plan denied your request. The Plan says the 
copayment applied 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for the Secretin injection. the Secretin injection falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the Secretin injection (J2850) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and unspecified preventive procedure 
provided on June 22, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and unspecified preventive procedure. You say that you don't 
agree with this decision. You say that insurance has to pay the bill. The Plan denied your request. The Plan says 
the 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, the contract also says that an intraoral 
x-ray is only covered 12 months after a panoramic x-ray. A panoramic x-ray was provided on December 17, 
2019, which exhausted your benefit. The unspecified preventive procedure is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay for the intraoral x-ray and unspecified preventive procedure 
provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wrist brace you received on June 26, 
2020. 
 
You asked the Plan to waive the coinsurance for the wrist brace. You say that you were told your responsibility 
should be $0 for this item. The Plan denied your request. The Plan says it initially processed your claim 
incorrectly and applied a copayment.  The Plan has since reprocessed the claim and applied 20% coinsurance 
for the wrist brace.  The Plan says that you have been charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetics and orthotics.  
 
You have been asked to pay 20% coinsurance for the wrist brace. The wrist brace falls within the prosthetics 
and orthotics benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the wrist brace you 
received on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) 
provided on July 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that you saw the same dentist in April. You say that 
those services were paid. You say that these services should be paid too. The Plan denied your request. The 
Plan says payment cannot be made for services that you receive from a dentist that 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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the oral evaluation (D0120) and prophylaxis (D1110) provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on September 
1, 2020. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was your yearly routine eye exam 
and should be billed as such. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct, because you were treated for medical issues and different tests were conducted at this visit. 
 
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 $35 
copayment for medical eye exam. This visit addressed several non-routine conditions; therefore, it is 
considered to be a medical eye exam and not a routine eye exam. 
 
You have been asked to pay $35 copayment for eye exam. Eye exam 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 an eye examination provided on September 1, 
2020.