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

 
We decided that the Plan does not have to pay for an additional unit for an ultrasound (CPT 76536) provided to 
the enrollee on August 24, 2020. 
 
You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says the submitted documentation support one unit of CPT 76536-26, which was previously 
approved/paid. 
 
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 76536 is "ultrasound, head/neck tissues, b-scan/real time 
with image documentation." 
 
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 additional unit. Our reviewer says that 
the services at issue in this case were not supported by the medical records. Our physician reviewer found the 
records enclosed show a single ultrasound of the neck done on 8/24/20 but two duplicate reports. The duplicate 
exams each are numbered 5958386 and were interpreted by the same radiologist. The claim states multiple 
different exams were done on 8/24/20 but the enclosed records only show the report of the ultrasound of that 
date. The second report of the same exam is simply a duplicate of the first. 
 
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 additional unit have not been met. Therefore, we decided that the Plan does 
not have to pay for an additional unit for an ultrasound (CPT 76536) provided to the enrollee on August 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 23, 2020.You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 or rest home visit provided on September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from July 2, 2020
to July 28, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that this should be covered because it is not a 
medical equipment charge. The Plan denied your request. The Plan says this was not billed with a valid 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 S9328 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 (S9328) provided from July 
2, 2020 to July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthesis with an advanced foot. 
 
You asked the Plan to pre-approve a new prosthesis with an advanced foot. You say that the items are 
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 a determination of the type of foot for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 new prosthesis with an advanced foot. 
Our reviewer says that the items are not medically necessary. Our physician reviewer found the treating 
medical provider notes do not support that you are a K3 ambulator. The request exceeds your medical needs 
and is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a new prosthesis with an advanced foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a new prosthesis with an advanced foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the toothpaste, first intraoral periapical x-ray, core buildup, 
including any pins when required, resin-based composite of one surface, resin-based composite of two surfaces, 
amalgam, two extractions, and problem focused limited oral evaluation, and pay more for the periodic oral 
evaluation, bitewings, and prophylaxis provided from March 10, 2020, to June 9, 2020 by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed. The Plan 
denied your request. The Plan says the toothpaste, first intraoral periapical x-ray, core buildup, resin-based 
composites, amalgam, extractions, and problem focused limited oral evaluation are not covered. The Plan also 
says that your claim processed correctly according to your OON benefits for the periodic oral evaluation, 
bitewings, and prophylaxis. 
 
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, toothpaste, first intraoral periapical x-
ray, core buildup, resin-based composites, amalgam, extractions, and problem focused limited oral evaluation 
are not among those covered under this benefit. The contract also clearly states that you must pay a 50% 
coinsurance for the periodic oral evaluation, bitewings, and prophylaxis when they are received OON. 
Therefore, we decided that the Plan does not have to pay for the toothpaste, first intraoral periapical x-ray, core 
buildup, including any pins when required, resin-based composite of one surface, resin-based composite of two 
surfaces, amalgam, two extractions, and problem focused limited oral evaluation, and pay more for the periodic 
oral evaluation, bitewings, and prophylaxis provided from March 10, 2020, to June 9, 2020 by an OON 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the echocardiogram and duplex scan 
rendered on March 6, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you should only have an $85 
copayment. 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 an $85 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility.  
 
Review of the file shows that you received an echocardiogram and duplex scan on March 6, 2020. You have 
been asked to pay an $85 copayment per test for these services, for a total of $170. These services fall within 
the Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or 
at a freestanding facility 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 copayments for the 
echocardiogram and duplex scan rendered on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided from July 23, 2020, through September 4, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that this is prescribed orthotics for treatment. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by St. Cloud 
Orthopedic Associates, LTD from July 23, 2020, through September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided a participating 
provider on August 28, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that all you had was an annual wellness 
exam. 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 $10 
copayment for physician/practitioner services/primary care physician.  
 
You have been asked to pay a $10 copayment for an office visit. When additional services are provided during 
an annual wellness exam, additional copayments can be applied; therefore, the correct copayment has been 
applied. An office visit falls within the physician/practitioner services/primary care physician 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 office visit provided by a participating provider on 
August 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found as you are not 
receiving skilled nursing or skilled therapy services, the requested services do not meet the definition of home 
health aide services and home health services are not reasonable and necessary to the treatment of your illness 
or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider from July 17, 2020, to August 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to you by an out-of-network 
provider from July 17, 2020, to August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zler Upright Walker. 
 
You asked the Plan to pre-approve a Zler Upright Walker. 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 must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers, as long as specific conditions are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Zler Upright Walker have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Zler Upright Walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two alveoloplasties in conjunction with extractions 
provided on September 4, 2020. 
 
You asked the Plan to pay for the alveoloplasties. You say that you would like this claim to be reconsidered. 
The Plan denied your request. The Plan says this service is not covered. 
 
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 two 
alveoloplasties in conjunction with extractions provided on September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care services provided from May 25, 2020, through 
July 23, 2020. 
 
You asked the Plan to pay for the urgent care services. The Plan denied your request. The Plan says there are 
no medical records or clinical documentation for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
 
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to 
justify payment of the claim. Based on this information, we decided that Medicare rules have not been met. 
Therefore, we decided that the Plan does not have to pay for urgent care services provided from May 25, 2020, 
through July 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health visits. 
 
You asked the Plan to pre-approve the additional home health services. You say that additional skilled visits 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 the additional home health services. 
Our reviewer says that additional skilled home health visits are not medically necessary. Our physician 
reviewer found the enrollee has had extensive prior skilled care and was provided additional sessions for 
education and disease management. The enrollee's needs do not require a skilled professional nurse beyond the 
visits that have already been approved. 
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 additional home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110), 
endodontic therapy (D3330), and resin-based composite (D2391) provided on July 30, 2020. 
 
You asked the Plan to pay for the emergency treatment of dental pain, endodontic therapy, and resin-based 
composite. You say that you contacted the Plan prior to receiving these services, and were told that you had 
coverage for a root canal. The Plan denied your request. The Plan says these services are not covered. The Plan 
also says that there are no records of you contacting the Plan prior to this date of service. 
 
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 
palliative (emergency) treatment of dental pain (D9110), endodontic therapy (D3330), and resin-based 
composite (D2391) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial lower dentures (D5214) and complete upper 
dentures (D5110). 
 
You asked the Plan to pre-approve partial lower dentures and complete upper dentures. You say that the 
requested items are necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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. The Plan covers complete 
upper and lower dentures or partial upper and lower dentures once every five years.  
 
We looked at the file and Medicare rules. Specifically, the record shows that you received partial lower 
dentures and complete upper dentures on February 18, 2020. This means that you are not eligible for health 
plan coverage of partial lower dentures and complete upper dentures at this time. Based on this information, we 
decided that the Plan's rules for coverage of partial lower dentures and complete upper dentures have not been 
met. Therefore, we decided that the Plan does not have to pre-approve partial lower dentures (D5214) and 
complete upper dentures (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code HCPCS 
A6535 that were issued on June 12, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code HCPCS 
A6535 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code HCPCS A6535 that were issued on June 12, 2020.