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

 
We decided that the Plan does not have to pay for the drugs you received on April 23, 2020, and April 24, 
2020. 
 
You asked the Plan to pay for the drugs. You say that the drugs should be covered. The Plan denied your 
request. The Plan says these drugs are not covered under your Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the drugs you received on April 
23, 2020, and April 24, 2020.  
 
Benefits for the drugs may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (L1971/LT/KX, L3170/LT/KX, 
L0650/KX, L1851/RT/KX, L2397/RT/KX, L3960/LT/KX, L2916/RT/KX and A4595-KX) provided on March 
23, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
based on the records submitted. 
 The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice or proof of delivery for the billed date of service. 
 
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 proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice and the delivery ticket is for a 
different date of service. 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 durable medical 
equipment (L1971/LT/KX, L3170/LT/KX, L0650/KX, L1851/RT/KX, L2397/RT/KX, L3960/LT/KX, 
L2916/RT/KX and A4595-KX) provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the echocardiography (93306) and injections 
(Q9950) provided on May 1, 2020. 
 
You asked the Plan to waive the cost share for the echocardiography (93306) and injections (Q9950). 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 an echocardiography and injections on 
the date of service at issue in this appeal. The Plan says that the correct cost share 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 Outpatient diagnostic tests and a 19% coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an 
echocardiography (93306) on May 1, 2020. You have been asked to pay a $90 copayment for the 
echocardiography. The echocardiography falls within the Outpatient diagnostic tests benefit category. The file 
also shows that you received injections (Q9950) on May 1, 2020. The injections fall within with Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the 
echocardiography (93306) and injections (Q9950) provided on May 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autograft for spine surgery (CPT 20936) provided on 
December 20, 2019. 
 
You asked the Plan to pay for CPT code 20936. You say that the records provided support the CPT code in 
dispute, which warrants separate payment. The Plan denied your request. The Plan says guidance upholds non-
payment for autograft for spine surgery. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. CPT code 20936 has a status indicator of B and has no separate 
Medicare payment. Therefore, we decided that the Plan does not have to pay for autograft for spine surgery 
(CPT 20936) provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 laboratory services provided on February 24, 
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
1, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance service 
was necessary because the hospital released the enrollee too soon so there should be no copayment. The Plan 
denied your request. The Plan says you were charged this cost sharing 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). The enrollee's contract with the Plan clearly says that the enrollee 
must pay a $225 copayment for each ambulance day of service. The enrollee had one ambulance day of 
service. The Plan charged $225 for these services. This means that the enrollee has been asked to pay the 
correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the ambulance services provided on April 1, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on March 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance transport services were 
medically necessary. The Plan denied your request. The Plan says that there was no contraindication to other 
modes of transportation. The Plan says that there was no evidence of a need for ambulance transportation and 
other means of transportation could have been used without endangering the individuals health. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the enrollee is a 46-year-old woman 
with type 2 diabetes, for whom an ambulance was called. The enrollees husband reported that the enrollee had 
not been taking her meds for a couple of days, and was acting very strange. EMS reported that the enrollee was 
hyperventilating on their arrival, but calmed down and felt better. She complained of nausea, and said that she 
had a fever a couple of days prior. Vital signs were notable for hypertension and tachypnea. BG measured 222. 
The enrollee was transferred to the hospital without incident. Our physician reviewer found that the enrollees 
presenting symptoms meet prudent layperson criteria for emergency care as it was believed that without 
immediate medical attention, there would be serious jeopardy to the enrollee's health. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pay for ambulance services provided on March 22, 2020.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider 
from May 22, 2020 through June 5, 2020. 
 
You asked the Plan to pay for physical therapy. You say that the enrollee is entitled to all Medicare approved 
services. You say that the office, provider and referring provider are all participating providers with Medicare. 
The Plan denied your request. The Plan says services rendered by nonparticipating providers require prior 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physical therapy provided by an out-of-network 
provider from May 22, 2020 through June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have a rare blood disease, and need a 
second opinion. The Plan denied your request. The Plan says the care requested can be provided by in-plan 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the oncology services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-
approve oncology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
November 11, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on November 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that upon assessment, the rescue team agreed 
transport without an ambulance would be acceptable. 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 January 30, 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45380) 
performed on November 18, 2019. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that no one ever mentioned 
to you that there would be a copayment and that you cannot afford to pay this bill. 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 $250 
copayment for each visit for Medicare-covered outpatient surgery.  
 
You have been asked to pay a $250 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" 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 a diagnostic 
colonoscopy (45380) performed on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first 15 minutes of intravenous moderate (conscious) 
sedation/analgesia and two subsequent 15 minute increments of intravenous moderate (conscious) 
sedation/analgesia provided on April 23, 2020. 
 
You asked the Plan to pay for the sedation/analgesia services. You say that the sedation was medically 
necessary because your teeth could not be extracted in a traditional setting. The Plan denied your request. The 
Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
15 minutes of intravenous moderate (conscious) sedation/analgesia and two subsequent 15 minute increments 
of intravenous moderate (conscious) sedation/analgesia provided on April 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of a new patient (99324), provided on March 30, 2020, by an out of network provider. 
 
You asked the Plan to pay for the practitioner service. You say that the service was medically necessary and 
appropriate. The Plan denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient 
(99324), provided on March 30, 2020, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (TENS unit), supplies, and 
orthotics provided on March 23, 2020. 
 
You asked the Plan to pay for TENS unit, supplies, and orthotics. You say that you are appealing with records. 
The Plan denied your request. The Plan says the denial of payment for these items is correct, because the 
documentation submitted does not include valid proof of delivery to support the claim billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The information submitted by the provider must 
corroborate the documentation in the medical record and confirm that Medicare coverage criteria have been 
met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid proof of 
delivery for the date of service billed on this claim. Without this information, you have not furnished sufficient 
information to the Plan to justify payment of the claim as billed. Based on this information, we decided that 
Medicare rules for coverage of TENS unit, supplies, and orthotics have not been met. Therefore, we decided 
that the Plan does not have to pay for a neuromuscular stimulator (TENS unit), supplies, and orthotics provided 
on March 23, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the compression system application provided on 
March 25, 2020. 
 
You asked the Plan to waive the copayment for the compression system application. You say that nothing 
received on this day could be considered surgical only therapy. You say that the appropriate member 
responsibility is one copayment. The Plan denied your request. The Plan says that the copayments 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). The enrollees contract with the Plan says that enrollees must pay a 
$25 copayment for each Medicare- covered occupational therapy visit.  
 
The Plan says the enrollee must pay a $30 copayment for the compression system application. Based on the 
plan contract, however, the enrollee cannot be asked to pay a separate copayment for the compression system 
application. The compression system application was done as part of a single occupational therapy visit under 
the plan of care. It would not be reasonable to assume that more than just the occupational therapy copayment 
would apply. Therefore, we decided that the Plan has to waive the copayment for the compression system 
application provided on March 25, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for mammography. You say that prior authorization is not required for this service. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and 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 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 December 12, 
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71045) provided on April 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The records show that the services in question were billed on a 
duplicate claim to one previously processed and paid by the Plan. 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 services (CPT 71045) provided on April 24, 2020.