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

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel 
services coded R0070 provided on August 26, 2020 
 
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not supported by the documentation. 
 
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 R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
We find that CPT code R0070 is not supported in the medical record. Specifically, the enrollee is not in an 
approved skilled nursing facility and there is no authorization on file for the services billed In addition, place of 
service 31 (skilled nursing facility) should be used with services for the enrollee's in a Part A covered stay and 
Place of service 32 (nursing facility) should be used with services for the enrollees in non-covered stays. Based 
on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray 
equipment and personnel services have not been met. Therefore, we decided that the Plan does not have to pay 
for the transportation of portable x-ray equipment and personnel services coded R0070 provided on August 26, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below the knee flexible protective cover system 
(L5962). 
 
You asked the Plan to pre-approve the flexible protective cover system. You say that the records provided 
support the need for the requested item. The Plan denied your request. The Plan says the item which remains in 
dispute is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are not 
covered for everyday usage in a typical environment. 
 
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 flexible protective cover system. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation does not reveal that the enrollee has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by the approved L5704. 
 
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 flexible protective cover system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a below the knee flexible protective cover system (L5962).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided 
on February 6, 2020. 
 
You asked the Plan to pay for office visit. You say that these visits have always been covered in the past. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible for 
Medicare coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
psychotherapy visit provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries services coded 93880 
provided on August 25, 2020. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. 
 
We find that CPT code 93880 is not supported in the medical record. Specifically, the documentation supports 
one unit of this code, which was previously submitted, approved, and paid by the Plan. There is no additional 
documentation supporting an additional study. Based on this information, we decided that Medicare rules for 
coverage of the duplex scan of extracranial arteries services have not been met. Therefore, we decided that the 
Plan does not have to pay for the duplex scan of extracranial arteries services coded 93880 provided on August 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records show that you were admitted for peripheral artery disease and 
ostemomyelitis of the right leg and had a right below the knee amputation. Your medical conditions are stable. 
There are no medical needs requiring inpatient admission. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contrast material rendered on August 11, 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 procedure code Q9967 is not supported. 
 
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 Q9967 is low osmolar contrast material, 300-399 mg/ml 
iodine concentration, per ml. 
 
We find that CPT code Q9967 is not supported in the medical record. Specifically, there is no documentation 
of 300-399 ml/ml of low osmolar contrast material. 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 contrast material rendered on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on August 18, 
2020. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you feel that the provider should 
be considered in-network. 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. The Plan 
contract with the Plan says that there is a $500 deductible for out-of-network physician/practitioner services, 
including doctor's office visits.  
 
The enrollee had a specialist visit on August 18, 2020, with an out-of-network provider. The record shows that 
the enrollee had paid $0 toward the $500 deductible prior to receiving the services. Therefore, the enrollee is 
responsible to pay the total allowed amount of $202.30. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible for out-of-network physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a 
specialist visit was received on August 18, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for a specialist visit provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from May 1, 2020, to May 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
Medicare eligible. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided from May 1, 2020, 
to May 29, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infection control services (D9999) provided on Jun 10, 
2020. 
 
You asked the Plan to pay for the infection control services. You say that you would like reconsideration 
because these services were an emergency. The Plan denied your request. The Plan says this 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 
infection control services (D9999) provided on Jun 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 8, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not urgent, emergent nor 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the office visit provided on September 8, 2020 by an out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on October 27, 2020. 
 
You asked the Plan to pay for the surgical extraction. You say that you contacted the Plan and were told that an 
emergency extraction would be covered. The Plan denied your request. The Plan says the extraction of a tooth 
is not considered preventive, and is considered a dental exclusion. 
 
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. The record shows that the provider contacted the Plan twice prior to 
the date of service, and was advised that you only had preventive dental benefits. Therefore, we decided that 
the Plan does not have to pay for the surgical extraction provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and vision services 
provided on September 14, 2020. 
 
You asked the Plan to waive the copayments for a specialist visit and vision services. You say that you disagree 
with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each specialist visit and a $35 copayment for vision care. 
 
You had a specialist visit on September 14, 2020. Therefore, you are responsible to pay the $35 copayment.  
 
You received vision services on September 14, 2020. Therefore, you are responsible to pay the $35 copayment.  
 
The total amount you owe is: $70.   
 
You have been asked to pay the total copayment amount of $70 for a specialist visit and vision services. A 
specialist visit falls within the physician/practitioner services, including doctor?s office visits benefit category. 
Vision services fall 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 copayments 
for a specialist visit and vision services provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 16, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says 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 had network providers 
available who could have provided 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 June 16, 2020, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasounds provided on August 10, 
2020. 
 
You asked the Plan to waive the copayments for the ultrasounds. You say that you think your share is too high 
and you should pay 20% of the claims. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $155 
copayment for each Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $155 copayment for each of the ultrasounds. ($155 x 2 = $310). The ultrasounds 
fall within the ?Outpatient Diagnostic Tests and Therapeutic Services and Supplies? benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the ultrasounds provided on August 10, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for laboratory tests provided on September 16, 2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges 
because you have never paid for labs in the past. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for laboratory services when provided in a specialist's office. 
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $10.94 
copayment for laboratory tests. The Plan contract does not clearly say how much enrollees must pay for 
outpatient diagnostic tests and therapeutic services and supplies. This means that the Plan did not follow 
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the 
copayment for laboratory tests provided on September 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires rendered on September 11, 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 must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than 
every twelve months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that the TENS device was rendered on January 8, 
2020. Replacement lead wires more often than every twelve months is not necessary. Therefore, we decided 
that the Plan does not have to pay for the lead wires rendered on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty Group 3 power wheelchair (K0862) and 
accessories. 
 
You asked the Plan to pre-approve a heavy duty Group 3 PWC and accessories. 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 group 3 PWC is covered when specific criteria is 
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 pre-approve a heavy duty Group 3 PWC and 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found K0862 
corresponds to a Power Wheelchair, Group 3 Heavy Duty, Multiple Power Option, Sling/Solid Seat/Back, 
Patient Weight Capacity of 301 to 450 Pounds. Your weight is documented to be 275lbs. 
 
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 heavy duty Group 3 PWC and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy duty Group 3 power wheelchair (K0862) and 
accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 26, 2020. 
 
You asked the Plan to pay for the testing services. You say that the lab performed the tests that were ordered by 
the referring physician. The Plan denied your request. The Plan says genetic screening testing is not a Medicare 
benefit when done without documentation of a medical indication. 
 
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 testing at issue is not supported in the medical record. Specifically, there are insufficient 
medical records to show that the results of the testing would be used to determine a specific diagnosis or 
treatment strategy. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 26, 
2020.