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

 
We decided that the Plan does not have to pay for a cerebral perfusion analysis using computed tomography 
(CT) provided. 
 
You asked the Plan to pay for CT cerebral perfusion analysis. You say that the provider performed this service 
and should be paid accordingly. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0042T is not covered by 
Medicare for date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT cerebral perfusion analysis have not been met. Therefore, we decided that the Plan does not 
have to pay for a cerebral perfusion analysis using computed tomography (CT) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density study provided on May 4, 2020. 
 
You asked the Plan to pay for the bone density study (77080). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this was a screening study and not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the bone density study, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the bone density study provided on May 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance service (A0429) ground mileage 
(A0425) provided May 2, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that the office made attempts to contact the 
enrollee for a possible auto carrier. There has been no response. Please process and follow up with subrogation 
if an auto carrier is made known. The Plan denied your request. The Plan says auto insurance carrier is primary. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary to 
the auto insurance carrier in all instances for claims resulting from a car accident. As the secondary insurer, the 
Plan cannot be held responsible for the ambulance service until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for BLS emergency ambulance service 
(A0429) ground mileage (A0425) provided May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5283). 
 
You asked the Plan to pre-approve the removable unilateral partial denture. The Plan denied your request. The 
Plan says this service is not covered under your benefit plan. 
 
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 pre-approve a 
removable unilateral partial denture (D5283).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit for the evaluation and management of 
a new patient (99205) provided June 18, 2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that please review the attached records for 
medical necessity as 99205 was billed 2 times on 6/18/20 and 06/04/20. The enrollee was seen by different 
providers, specialties and DX codes. The Plan denied your request. The Plan says new patient qualifications 
were not met. The providers in the same group and specialty would be considered the same provider and the 
patient visit would be considered established verses new. 
 
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 billing of code 99205 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
 
 
decided that the Plan does not have to pay for outpatient office visit for the evaluation and management of a 
new patient (99205) provided June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee would like to continue seeing the 
requested provider. The Plan denied your request. The Plan says out-of-network services 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve medical 
services 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 physician's services that you provided on September 16, 
2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network 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 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 physician's services that you provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs to monitor 
his sugars. The Plan denied your request. The Plan says you were already approved for a continuous glucose 
monitor. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
The file shows that the enrollee has a Freestyle libre monitor. This device serves the same purpose as the 
requested continuous glucose monitor. The records do not show that the enrollees insulin treatment regimen 
requires frequent adjustment based on the testing results. Based on this information, we decided that the 
Medicare coverage rules have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided.

You asked the Plan to waive the copayments for wound debridement. You say that you disagree with the charges because you were not charged in the past and the procedure only takes a few minutes. 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 $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received wound debridement  for a total of 4 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 copayment per each visit. The total amount you owe is: $225 (copayment) x 4 (wound debridement services) = $900. 

You have been asked to pay a $225 copayment for wound debridement. Wound debridement 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 copayments for wound debridement provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of brain (70551) 
provided on April 14, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI) of brain. You say that no prior 
authorizations are obtained for urgent care visits and would like this claim reprocessed and approved for 
payment. 
 The Plan denied your request. The Plan says the provider should have verified the member's eligibility, health 
benefits, and obtained authorization prior to the member's visit. 
 
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 magnetic resonance imaging (MRI) of brain 
(70551) provided on April 14, 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 an ambulance trip provided by a participating provideron May 15, 2020.You asked the Planto waive the copayment for an ambulance trip. You say that you think this should be processed as in-network. 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 $250 copayment for ambulance services/out-of-network. You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the ambulance services/out-of-network benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 ambulance trip provided by a non-participating provider on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for oral exam (D0120), prophylaxis (D1110), and 
bitewing x-rays (D0274) provided on March 2, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you are disappointed with your 
policy. You say that you chose this plan for the dental reimbursement feature. You also say that the plan should 
change the policy to allow for reimbursement from opt out providers. The Plan denied your request. The Plan 
says dental services you received from a provider that has opted out of Medicare are not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Additionally, the Evidence of Coverage clearly states that the 
enrollee will be fully responsible for all dental services from a provider who has opted out of Medicare. 
Therefore, we decided that the Plan does not have to reimburse you for oral exam (D0120), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that the ventilator is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that home ventilators are covered when medically 
necessary. 
 
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 non-invasive home ventilator. Our 
reviewer says that the ventilator is not medically necessary. Our physician reviewer found the enrollee has 
severe COPD and pulmonary hypertension, with chronic hypercarbic respiratory failure. He may benefit from 
BiPAP at night. Medicare does not cover a ventilator when used as BiPAP. Certain BiPAP devices are capable 
of providing the AVAPS mode of support that has been ordered. 
 
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 non-invasive home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure (C-
PAP) supplies you received on May 21, 2020. 
 
You asked the Plan to waive the coinsurance for the C-PAP supplies. You say that you are constantly paying 
these bills and the amount keeps going up. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the C-PAP supplies. The C-PAP supplies fall within the 
durable medical equipment and related 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 
coinsurance for continuous positive airway pressure (C-PAP) supplies you received on May 21, 2020.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for physical therapy provided on February 28, 2020. We 
decided that the Plan does not have to waive the copayment for physical therapy provided on February 26, 
2020, and March 4, 2020.  
 
You asked the Plan to waive the copayment for physical therapy. You say that you feel this is pricey for the 
length of the appointments. The Plan says that the copayment you are being charged is correct. 
 
We decided that the Plan has to reduce the copayment for physical therapy provided on February 28, 2020.  
 
The Plan contract says that enrollees must pay a $40 copayment for each Medicare-covered physical therapy 
visit. Therefore, we decided that the Plan has to reduce the copayment for physical therapy received on 
February 28, 2020, and cannot charge you more than $40 for this visit.  
 
We also decided that the Plan does not have to waive the copayment for physical therapy provided on 
February 26, 2020, and March 4, 2020. 
 
 
 
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 $40 
copayment for physical therapy. Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy provided on February 26, 2020, and March 4, 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost for the echocardiography and perflutren lipid microspheres 
injection provided on June 15, 2020. 
 
You asked the Plan to reduce the cost for the echocardiography and perflutren lipid microspheres injection. 
You say that you were billed $25 for the echo and $62.69 for the injection. You say that you shouldn't be billed 
for both when it was done in conjunction with the procedure. The Plan denied your request. The Plan says that 
the cost share applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees pay a $0 copayment for Medicare-covered lab services and diagnostic 
procedures/tests performed in a physician's office. Your contract with the Plan does not say in clear and 
accurate terms how much you should expect to pay for medical supplies. 
 
The Plan says you must pay a $25 copayment for the echocardiography as an x-ray service and 20% 
coinsurance for the perflutren lipid microspheres as a Part B drug. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the echocardiography and $0 for the perflutren lipid 
microspheres injection. The echocardiography is considered a diagnostic test that was performed in a 
physician's office. The perflutren lipid microspheres is considered a medical supply which does not have a cost 
you should expect to pay listed in the EOC. Therefore, we decided that the Plan has to waive the cost for the 
echocardiography and perflutren lipid microspheres injection provided on June 15, 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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a prostate ultrasound (76873). 
 
You asked the Plan to pre-approve a prostate ultrasound. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prostate ultrasound. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested transrectal prostate ultrasound will allow for accurate assessment of 
prostate size and sonographic evaluation of both the central and peripheral zones as well as the evaluation of 
the peri prostatic area to determine if there is an abnormality around the gland causing your symptoms of 
urgency and frequency. If the gland is found to be normal except for enlargement the treatment options will be 
clarified. It should be noted that if the prostate ultrasound is found to be normal, prostate cancer is not excluded 
by a normal prostate ultrasound without a biopsy. 
 
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 prostate ultrasound have been met. Therefore, we decided that the Plan has to 
pre-approve a prostate ultrasound (76873).  
 
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.