Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid (V5298) provided on June 16, 2020. 
 
You asked the Plan to pay for hearing aid. You say that the service should be covered. The Plan denied your 
request. The Plan says there is no coverage if hearing aids or related services are received from a provider not 
part of the plans hearing aid vendor?s network and the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through a Plan network provider and registered in advance.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aid have not been met. Specifically, you received your hearing aid from a provider that 
was not in the Plans hearing network and did not register the service in advance. Therefore, we decided that 
the Plan does not have to pay for hearing aid (V5298) provided on June 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasounds provided on September 2, 2020. 
You asked the Plan to waive the copayments for the ultrasounds. You say that this was a very simple procedure 
and you are shocked by the total charge. 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 $125 
copayment for each Medicare-covered radiological diagnosis service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
You have been asked to pay a $220.18 copayment for the ultrasounds. 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 September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and 
ultrasound provided on September 25, 2020. 
 
You asked the Plan to waive the copayments for the diagnostic mammogram and the ultrasound. You say that 
you were told this service was supposed to be free because you are allowed a free preventive mammogram. 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 $40 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay a $40 copayment for the diagnostic mammogram and a $40 copayment for the 
ultrasound. The diagnostic mammogram and the ultrasound fall within the ?Outpatient diagnostic tests and 
therapeutic services and supplies? benefit category. The medical record shows the mammogram and ultrasound 
were provided due to left breast focal pain. This makes the mammogram diagnostic in nature. 
 
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 diagnostic mammogram and the ultrasound provided on 
September 25, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided. 
 
You asked the Plan to pay for emergency room services. You say that the records support this service. The Plan 
denied your request. The Plan says this code is not payable as billed. 
 
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, we have confirmed that code 99284 
services has a Column One/Column Two relationship with code 99285, which was billed by the same provider 
for this date of service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (99284) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 Vertiflex Superion device placement
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has chronic back pain. The requested device
is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet
criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we
decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (71046) and physician services
(94010) provided September 28, 2020, to October 29, 2020.
You asked the Plan to waive the copayment for the x-ray and physician services. You say that these services
were related to COVID and the copayments should be waived. The Plan denied your request. The Plan says the
correct cost-sharing 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 $15
copayment for x-rays and a $35 copayment for specialist visits.
You have been asked to pay a $15 copayment for the x-ray and a $35 copayment for specialist physician
services. 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 x-ray (71046) and physician services
(94010) provided September 28, 2020, to October 29, 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 your medical conditions are stable. There are no medical needs requiring inpatient
admission. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that
you require an intensive rehabilitation therapy program. Your care needs can be met at lower level of care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network provider.
You asked the Plan to pre-approve an office visit with an out of network provider. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 an office visit with an out of network
provider. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found you had a history of posterior vitreous detachment in the
right eye. You presented to the non-network ophthalmologist with complaints of floaters in the right vision.
Visual acuity measured 20/125 right eye and 20/25 left eye. The examination showed right posterior vitreous
detachment and bilateral cataract. Diagnosis was vitreous detachment and cataract. Continued service with the
non-network ophthalmologist for the vitreous detachment and symptoms of floaters is not medically necessary.
the documentation shows that you had vitreous detachment that requires follow-up observation and can be
safely treated medically by an ophthalmologist within the health plan's network. Records indicate that the
symptomatic floaters were benign and that transfer of follow-up care would not pose any additional health risk.
Therefore, you do not meet criteria for the requested out of network office visit. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an office visit with an out of network provider have not been met. Therefore, we
decided that the Plan does not have to pre-approve an office visit with an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that a basic pump does not meet 
the enrollee's needs, so this is the appropriate device. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because the enrollee has not undergone a 4-week trial using a basic 
compression pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 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 treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, multiple-hour 
home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who 
is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the 
Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient diagnostic test provided on 
July 6, 2020. 
 
You asked the Plan to waive the copayment for the outpatient diagnostic test. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received an outpatient diagnostic test on the date of service at issue in 
this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient 
diagnostic test on July 6, 2020. You have been asked to pay a $30 copayment for the outpatient diagnostic test. 
The outpatient diagnostic test falls within the Outpatient diagnostic tests 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 the outpatient diagnostic test provided on July 6, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray of the neck and spine (72052) provided on July 9, 2020. 
 
You asked the Plan to pay for the x-ray of the neck and spine. You say that you would like reconsideration 
because these codes may be paid as billed and there are not any CCI conflicts. The Plan denied your request. 
The Plan says that CPT code 72052 is a column II code to CPT code 72082 which was billed for the same date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-ray of the neck and spine have been met. Specifically, the record shows that the column I 
code was billed and paid to a physician with a different NPI. It is not appropriate to apply NCCI edits to codes 
billed for different NPIs. Therefore, we decided that the Plan has to pay for the x-ray of the neck and spine 
(72052) provided on July 9, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemodenervation of the extremity
(64642) provided on September 8, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $150
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $150 copayment for the outpatient surgery provided. 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 the chemodenervation of the extremity (64642) provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction of an impacted tooth (D7230) for tooth # 
17. 
 
You asked the Plan to pre-approve the dental service. You say that you are experiencing excruciating pain. You 
say that your dentist advised an extraction is recommended to alleviate symptoms and prevent complications 
such as pain. The Plan denied your request. The Plan says extraction of an impacted tooth 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
extraction of an impacted tooth (D7230) for tooth # 17.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0012M) provided July 7, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services were screening tests and are not a covered benefit. 
 
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 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 genetic testing 
(0012M) provided July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous sedation (D9239). 
 
You asked the Plan to pre-approve intravenous sedation (D9239). The Plan denied your request. The Plan says 
the service 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 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 
intravenous sedation (D9239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to get a second opinion. The 
Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 items/services at issue in this appeal. 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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve capecitabine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve capecitabine.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (CPT 97110, CPT 97010) provided 
on July 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (CPT 97110, CPT 97010) provided on July 21, 
2020.