Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 23, 
2020 through March 25, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your 
copayment because it is not listed on your identification card. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on March 23, 2020 and discharged on March 25, 2020. You 
were asked to pay a $250 copayment per day from March 23, 2020 through March 24, 2020, days 1-2 of your 
inpatient hospital care. You were discharged on March 25, 2020 and there was no copayment charge for the 
day of discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care from March 23, 2020 through March 25, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee 
on December 23, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the orthoses are medically necessary. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthoses have not been met. Documentation submitted did not 
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be 
verified. Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) 
provided to the enrollee on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve the overdenture. You say that you need new dentures. The Plan denied your 
request. The Plan says this service is not covered under your benefit package. 
 
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 pre-approve a 
complete mandibular overdenture (D5865).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the walker (E0143) to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the walker. You say that the walker requested is medically necessary. The 
Plan denied your request. The Plan says the requested type walker is not provided by a network provider. 
Additionally, the supplier of the specific walker requested does not accept Medicare payment. 
 
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 durable medical equipment. We found no exception that would require the Plan to 
pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the walker 
(E0143) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on February 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider without prior authorization. Additionally, the care provided was not an urgently needed service.  
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The service at issue in this appeal was not provided in an emergency or urgent care situation. The service was 
not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have 
to pay for the office visit (99214) provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the foot orthotics purchased on January 14, 2020. 
 
You asked the Plan to reimburse for foot orthotics. You say that you are appealing for reconsideration of the 
denied charges. 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 reimburse for the foot orthotics purchased on 
January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy pouch, drainable, with barrier attached, with built-in 
convexity (1 piece), each (A4389), ostomy deodorant, with or without lubricant, for use in ostomy pouch, per 
fluid ounce (A4394) and adhesive remover, wipes (A4456) provided to the enrollee from May 16, 2019 
through August 14, 2019. 
 
You asked the Plan to pay for the DME. You say that the claims should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Based on this information, we decided that Medicare rules for coverage of the DME have not been met. 
Healthcare Common Procedure Coding System (HCPCS) code A4389 (60 Units) remains not supported. The 
documentation submitted did not include a valid physician order; therefore, the billed service cannot be 
verified. Of note, the submitted order does not indicate the physician's signature (signed by the ordering 
physician). It is noted that multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A4456 (150 Units) remains not supported. The 
documentation submitted did not include a valid physician order; therefore, the billed service cannot be 
verified. Of note, the submitted order does not indicate the physician's signature (signed by the ordering 
physician). It is noted that multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A4394 (24 Units) remains not supported. The 
documentation submitted did not include a valid physician order; therefore, the billed service cannot be 
verified. Of note, the submitted order does not indicate the physician's signature (signed by the ordering 
physician). It is noted that multiple attempts were made to contact the provider for additional information. 
Therefore, we decided that the Plan does not have to pay for ostomy pouch, drainable, with barrier attached, 
with built-in convexity (1 piece), each (A4389), ostomy deodorant, with or without lubricant, for use in ostomy 
pouch, per fluid ounce (A4394) and adhesive remover, wipes (A4456) provided to the enrollee from May 16, 
2019 through August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on April 27, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges 
because you never paid a copayment in the past. 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 $20 
copayment for specialist services.  
 
You have been asked to pay a $20 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctors office visits 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 specialist services provided on April 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from May 30, 2019 
through June 5, 2019 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you saw two different 
providers leading up to your hospitalization and you believe they misdiagnosed your condition which lead you 
to being hospitalized. The Plan denied your request. The Plan says the claim was processed accordingly with 
your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care from May 30, 2019 through June 5, 2019 by 
an in-network provider. You were asked to pay a $750 copayment for the inpatient hospital care. Your EOC 
states that enrollees must pay a $750 copayment per stay for each in-network medically necessary covered 
inpatient stay after you pay your $1,000 deductible. 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 
inpatient hospital care from May 30, 2019 through June 5, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a power scooter (K0801). 
 
You asked the Plan pre-approve the power scooter. You say that the power scooter is medically necessary. The 
Plan denied your request. The Plan says the enrollee currently walks independently however their condition 
could be ameliorated by a walker which has been approved. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The evaluation included in the file concludes that the enrollees mobility deficit could be improved with a 
walker, which the plan has already approved. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have pre-approve a power scooter (K0801).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the golf membership purchased from May 5, 2020 
through May 19, 2020. 
 
You asked the Plan to reimburse for the golf membership. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says they are unable to locate your name based on 
the receipts provided. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We are unable to locate your name based on the receipts provided. Furthermore, if this membership is for a golf 
club it would be denied as well. Your EOC states, " You must submit an itemized receipt or other proof of 
payment and proof of participation for reimbursement to the Plan" and "Other membership-based facilities such 
as spas, golf clubs, or country clubs do not qualify for reimbursement, even if the facility includes gym access." 
Therefore, we decided that the Plan does not have to reimburse for the golf membership purchased from May 
5, 2020 through May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for determination of refractive state (92015) provided to the enrollee on 
February 6, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says that you pay 40% coinsurance for an out-of-
network provider for Medicare vision services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states this provider is in-network with your Plan; however, Original 
Medicare doesn't cover routine eye exams (eye refractions) and they told you it was processed with your EOC 
with 40% coinsurance. The EOC states that covered services include: Outpatient physician services for the 
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts and 
you pay 20% for out-of-network Medicare-covered vision services. Furthermore, the Plan did not notify us if 
the provider participated with your supplemental vision plan network which this eye refraction would fall 
under. Your EOC states that you pay any amount over $75 for an out-of-network routine eye exam (1 per 
calendar year) eye exam will include refraction and dilation. Therefore, since the Plan did not provide accurate 
information the request should be overturned for the eye refraction. Therefore, we decided that the Plan has to 
pay for determination of refractive state (92015) provided to the enrollee on February 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased by the enrollee on March 16, 
2020 from an out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says hearing aids ordered through a provider other than a 
network Plan provider is not covered. 
 
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. 
 
Review of the file show that the enrollee purchased hearing aids on March 16, 2020 from an out-of-network 
provider. The enrollee's EOC states that hearing aids ordered through a provider other than a network Plan 
provider is not covered. 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 hearing aids purchased by 
the enrollee on March 16, 2020 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a queen size adjustable bed purchased on February 13, 2020 
from a non-contracted vendor. 
 
You asked the Plan to pay for the bed. You say that you contacted the Plan to obtain in-network suppliers that 
carry the bed for your prescription. You stated that you contacted the suppliers and were advised the only had 
twin size hospital beds available. The Plan denied your request. The Plan says the bed purchased was not a 
hospital bed. Additionally, the provider you purchased the bed from is not a covered vendor. 
 
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 bed purchased was not a hospital bed. Furthermore, this provider is not a covered vendor. 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 a queen size 
adjustable bed purchased on February 13, 2020 from a non-contracted vendor.
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 
February 4, 2020. 
 
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 
enrollee's 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 February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0651). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support documented 4 weeks of 
conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to conservative therapy including exercise, elevation and regular use of 
compression stockings.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, documented conservative therapy. Therefore, we decided that the Plan does not 
have to preapprove a pneumatic compression device (E0651).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this facet joint injection is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be indicated when the 
clinical criteria above have been 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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found the requested procedure is supported for predominantly axial pain that is not associated with 
radiculopathy or neurogenic claudication. The office notes indicate the enrollee has chronic back pain with 
radiculopathy. There is non-facet pathology that could explain the source of the enrollee's pain. There is no 
clinical assessment that implicates the facet joint as the putative source of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0676). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to 
prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device 
is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to preapprove a pneumatic compression device (E0676).