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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit from May 3 to 
May 4, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An 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 an 
emergency room visit from May 3 to May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for 
restorative procedure (D4212) provided on May 26, 2020. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that the bridge needed to be replaced 
due to recurrent caries. The Plan denied your request. The Plan says this 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 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) provided on May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on April 7, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the LSO is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found while "ddd l/s spine" is on the enrollee's 
problem list, there is no documented complaint of back pain. The documentation does not support that the 
lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no 
documentation of a physical examination of the back. The services were therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 lumbar-sacral orthosis (LSO) rendered on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedist 
on June 16, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were unable to return to the 
orthopedist's office for a post-op visit earlier due to COVID-19. The Plan denied your request. The Plan says 
you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the office visit. This cost sharing applies regardless of the 
reason for the delay in your visit. 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 office visit you had 
with an orthopedist on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on April 1, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis rendered on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on May 
17, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you had a COVID-19 
test and should not owe a copayment. 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 $35 
copayment for urgently needed services.  
 
You have been asked to pay a $35 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
urgently needed services provided on May 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services rendered on September 13, 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 services from an out-of-network provider are not covered. 
 
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 does not cover routine eye exams from an out-of-network provider. 
 
We looked at the file and the Plan's rules. The file shows that the services were rendered by an out-of-network 
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 routine vision services rendered on 
September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided on May 24, 
2020. 
 
You asked the Plan to pay for a total electric hospital bed. You say that you believe hospital beds are covered 
under Medicare. The Plan denied your request. The Plan says total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
 
We looked at the file and Medicare rules. The item at issue is a total electric hospital bed, which is not covered. 
Based on this information, we decided that Medicare rules for coverage of a total electric hospital bed have not 
been met. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed (E0265) 
provided on May 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 28, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX-Z code identifier must be entered adjacent to the CPT 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on April 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by North Area Volunteer 
Ambulance Corps, Inc. on February 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were at a restaurant and your nose 
would not stop bleeding. The EMT's came and treated you in place. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 22, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by North Area 
Volunteer Ambulance Corps, Inc. on February 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (S0500) provided on January 13, 2020. 
 
You asked the Plan to pay for contact lenses. You say that you should not be responsible for the cost of the 
contact lenses. The Plan denied your request. The Plan says contact lenses are only covered following cataract 
surgery, 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for contact lenses (S0500) provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on March 2, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing rendered on March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not allowed to 
drive the enrollee and request the ambulance services be covered. The Plan denied your request. The Plan says 
the claims were processed correctly and the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance services.  
 
The enrollee has been asked to pay the allowed amount of $227.18, which is less than the $250 copayment for 
ambulance services. Ambulance services fall within the ambulance services benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Neuromuscular stimulator, electronic shock unit provided 
on April 9, 2020. 
 
You asked the Plan to pay for the Neuromuscular stimulator, electronic shock unit (E0745). You say that the 
device was medically necessary. The Plan denied your request. The Plan says the records do not support 
medical necessity for this device. 
 
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 pay for the Neuromuscular stimulator, electronic 
shock unit (E0745). Our reviewer says that the Neuromuscular stimulator was not considered medically 
reasonable and necessary in this case. Our physician reviewer found this enrollee has chronic lower extremity 
pain and a transcutaneous electrical nerve stimulation unit and supplies were ordered. There is no History and 
Physical exam, review of systems or review of medications. 
 
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 Neuromuscular stimulator, electronic shock unit (E0745) have not been met. 
Therefore, we decided that the Plan does not have to pay for the Neuromuscular stimulator, electronic shock 
unit provided on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 7, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9338) provided on December 4, 
2019. 
 
You asked the Plan to pay for home infusion therapy. You say that this should be covered. The Plan denied 
your request. The Plan says this was billed with an invalid 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. 
 
We find that CPT code S9338 is not supported in the medical record. Specifically, this code has a status 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9338) provided on 
December 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-emergency wheel-chair van transport provided on 
March 27, 2020. 
 
You asked the Plan to pay for a non-emergency wheel-chair van. You say that due to your condition you 
needed to be taken by an ambulance. The Plan denied your request. The Plan says wheelchair van (chair car) 
transportation is not covered even if provided by an ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Emergency Medical 
Transport is not a covered benefit. Per your 2020 EOC, wheelchair van (chair car) transportation is not covered 
even if provided by an ambulance company. Therefore, we decided that the Plan does not have to pay for a 
non-emergency wheel-chair van transport provided on March 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography (77067) provided on December 
8, 2017. 
 
You asked the Plan to pay for the screening mammography. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code has a status code of I which is 
invalid for Medicare purposes. 
 
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 77067 is not supported in the record. Specifically, per the Physician Fee Scehdule, on 
the billed date of service, CPT code 77067 has a status indicator of I. This means that CPT code 77067 was not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
screening mammography have not been met. Therefore, we decided that the Plan does not have to pay for a 
screening mammography (77067) provided on December 8, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Broda Chair purchased on April 14, 2020 from a non-
Medicare provider. 
 
You asked the Plan to pay for the Broda Chair. You say that the durable medical equipment is medically 
necessary. The Plan denied your request. The Plan says the provider is not a Medicare participating provider. 
 
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 provider is not a Medicare participating provider. The enrollee's EOC states, "you can get your care from 
an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. 
Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from 
the Medicare Program. If you receive care from a provider who is not eligible to participate in Medicare, you 
will be responsible for the full cost of the services you receive." 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 Broda Chair purchased on April 14, 2020 from a non-Medicare provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 9, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you feel that the ambulance staff were unprofessional. The Plan denied your request. The Plan says the 
claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance services.  
 
The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within 
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute care nurse practitioner visit you 
had on January 30, 2020. 
 
You asked the Plan to waive the copayment for the acute care nurse practitioner visit. You say that this 
copayment should be waived because you were in the hospital on this date.  You say that this service should be 
included in your admission. The Plan denied your request. The Plan says you were not an inpatient on this date 
of service.  Instead, you were in the hospital under observation, which is an outpatient status.  Because you 
were an outpatient, the copayment was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for specialist visits in an outpatient hospital setting.  
 
You have been asked to pay a $35 copayment for the acute care nurse practitioner visit. You were in an 
outpatient status at the hospital, so a copayment can apply to visit you had while you were there. 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 acute care nurse practitioner visit you had on January 30, 2020.