Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter, infusion supplies, and the milrinone lactate injection. 
 
You asked the Plan to pay for the supplies for maintenance of non-insulin drug infusion catheter, infusion 
supplies, and the milrinone lactate injection. 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. 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. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate that 
specific supplies were delivered to the enrollee or proof of delivery for the billed dates 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 the supplies for maintenance of non-insulin drug infusion 
catheter, infusion supplies, and the milrinone lactate injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97214) provided July 26, 2019 to 
December 23, 2019. 
 
You asked the Plan to pay for the massage therapy. You say that you have been continuing to go for therapeutic 
massage on a regular maintenance schedule, to prevent the necessity of having the services you came to 
urgently need. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy (97214) provided July 26, 2019 to 
December 23, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on April 18, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with 
this copayment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the emergency 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 copayment for an 
emergency room visit provided by a participating provider on April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to waive the deductible forprimary care office visits and laboratory testing provided from May 9, 2020, to May 14, 2020.You asked the Plan to waive the deductible foroffice visits and lab test. You say that you do not understand why these claims were filed as out-of-network.The Plan denied your request. The Plan says the deductible amounts you are being charged are correct.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 there is $750 deductible for out-of-network primary care visits and lab tests. At the time these claims were processed, $0 of the $750 deductible had been met. The allowed amounts of these claims total $223.67, resulting in a deductible obligation of $223.67.The itemsor servicesyou asked the Plan to waive the deductible for fall within the benefit categories"Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies". The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for "Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies". This cost sharing is a contractual obligation that had not been met at the time office visits and lab test was received on May 9, 2020 to May 14, 2020.Therefore, we decided that the Plan does not have to waive the deductible forprimary care office visits and laboratory testing provided from May 9, 2020, to May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetics only, fitting, custom preparation and supply of 
off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe (A5500 RT, LT) 
provided. 
 
You asked the Plan to pay for the orthotics. You say that you have attached medical records to support medical 
necessity. Please reprocess claim for payment as these services provided were medically necessary. The Plan 
denied your request. The Plan says the validity and accuracy of the billed code and modifiers cannot be 
verified. 
 
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 physician order for the supplies provided in this case. The submitted 
physician's order does not include a completed physician?s order, including a complete detailed description of 
the Durable Medical Equipment being ordered and/or a list of all separately billable supplies being ordered. 
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 the diabetics only, fitting, custom preparation and 
supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe (A5500 
RT, LT) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laparoscopy surgery provided on May 21, 
2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were an inpatient for this 
surgery. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $450 
copayment for outpatient surgery at an outpatient hospital facility. The record shows that your patient status for 
this surgery was outpatient, therefore the outpatient copayment applies to this claim. 
 
You have been asked to pay $450 copayment for outpatient surgery. Outpatient surgery 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 laparoscopy surgery 
provided on May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 6, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT81479 (for the entire multi-test panel). 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on May 20, 2020. 
 
You asked the Plan to pay for the (TENS) device. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says TENS units are not covered for chronic low back and neck pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does support chronic low back pain and does not show the 
enrollee is enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for 
coverage of the (TENS) device. have not been met. Therefore, we decided that the Plan does not have to pay 
for the transcutaneous electrical nerve stimulation (TENS) device provided on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 orthotics rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation, intraoral x-ray and 
prophylaxis provided by an out-of-network provider on April 20, 2020. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, intraoral x-ray and prophylaxis. You 
say that you are disputing a balance of $394. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for the comprehensive oral evaluation, intraoral x-ray and prophylaxis when received from an 
out-of-network provider. You are responsible for the difference between the billed and allowed amount. 
Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, intraoral 
x-ray and prophylaxis provided by an out-of-network provider on April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided December 
10, 2019 to December 14, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you met your 
maximum for out-of-pocket expense at the time services were rendered, and the copayment should be waived. 
The Plan denied your request. The Plan says the maximum was not met and 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 $300 
per day copayment for days 1-5 of inpatient hospital care. 
 
You have been asked to pay a $1200 copayment for 4 days of inpatient hospital care ($300 per day). This 
means that you have been asked to pay the correct amount based on your contract with the Plan. The record 
shows that after the services at issue, you reached $6,401.95 of the allowable $6,700 out-of-pocket maximum. 
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 provided December 10, 
2019 to December 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the chest providedon January 28, 2020.You asked the Plan to pay for the x-ray. 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 toget 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 an x-ray of the chest provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on February 25, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99213) provided on February 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied to lab services you received on April 
16, 2020. 
 
You asked the Plan to waive the deductible applied to the lab services. You say that you should not have to pay 
for these services because this was a Welcome to Medicare Wellness visit. The Plan denied your request. The 
Plan says you were charged this deductible 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 there is a $500 annual deductible that applies to lab services. 
 
Your EOC clearly states that labs are not included as part of your Annual Wellness or Welcome to Medicare 
exams rather, cost sharing applies for these services.  Your EOC also clearly states that you have to meet 
your $500 deductible (which applies to lab services) before your Plan will pay for your care. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 annual deductible that applies 
to the lab services you had. This cost sharing is a contractual obligation that had not been met at the time the 
lab services was received on April 16, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible applied to lab services you received on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture with a flexible base (D5226) 
provided on December 19, 2019. 
 
You asked the Plan to pay for the dental item. You say that the denture did not fit when you received it 
initially. You say that you were charged an additional $400 on top of the $1,000 you have already paid. You 
also say that you refuse to go back to this provider. The Plan denied your request. The Plan says the lower 
partial denture with a flexible base is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture with a flexible base 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
lower partial denture with a flexible base (D5226) provided on December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S5501) provided to the enrollee from January 10, 2020 to January 26, 2020.You asked the Planto pay forthe therapy. You say that this should be paid for.The Plandenied your request. The PlansaysHCPCS code S5501 denied as invalid procedure code for this service and remains denied.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the CPT Code Manual definition of HCPCS code S5501 is "Home infusion therapy, catheter care/maintenance, complex."We find that HCPCS code S5501 is not supported in the medical record. Specifically, this code has a status indicator of I, meaning that it is invalid for Medicare use. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met.Therefore, we decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S5501) provided to the enrollee from January 10, 2020 to January 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair (K0813) purchased on 
April 10, 2020. 
 
You asked the Plan to pay for a power wheelchair. You say that you needed this item and it was least expensive from the other supplier. The Plan denied your request. The Plan says items purchased from suppliers that are not enrolled 
in Medicare are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The item at issue was not purchased from a supplier that is enrolled 
in the Medicare program. Based on this information, we decided that Medicare rules for coverage of a power 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a power wheelchair 
(K0813) purchased on April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services provided from January 23, 2020, to 
February 11, 2020 by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that you were not informed of the provider's 
non-network status prior to receiving the services. The Plan denied your request. The Plan says these services 
were rendered by an OON provider. The Plan also says that there are no call records on file of you calling to 
obtain an in-network dental provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve the 
dental services provided from January 23, 2020, to February 11, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on May 7, 2020.You asked the Plan to pay for the pathology 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 Plandid not pre-approve the pathology services.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 pathology servicesprovided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis provided to the enrollee on December 26, 2019. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee's geographical area is not an eligible geographic area that qualifies for 
telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an orthosis provided to the 
enrollee on December 26, 2019.