Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism and equipment purchased on April 6, 
2020. 
 
You asked the Plan to pay for this equipment. You say that the Plan should cover this equipment. The Plan 
denied your request. The Plan says you did not have prior authorization and the provider is not an eligible 
Medicare program provider. 
 
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 is not eligible to participate in the 
Medicare program. The furniture store this equipment was purchased from is not a Medicare program provider.  
Therefore, we decided that the Plan does not have to pay for a seat lift mechanism and equipment purchased on 
April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you have a bad back and have 
difficulty ambulating. The Plan denied your request. The Plan says the record shows your home is not 
appropriate for a power scooter. 
 
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 file shows that your condition can be improved by a rolling walker and a cane. Your home assessment 
shows your home cannot accommodate a power operated vehicle. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator garment provided on May 
1, 2020, by an OON provider. 
 
You asked the Plan to pay for the automatic external defibrillator garment. The Plan denied your request. The 
Plan says the service was rendered by a non-network provider. The Plan also says that the service was not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 automatic external defibrillator garment 
provided on May 1, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer 
must be billed first. 
 
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 has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) services provided to the 
enrollee. 
 
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 the technical report did not include documentation of an electroencephalogram (EEG) during 
nonintracranial surgery (carotid surgery); therefore this code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27236 is "Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery)." 
 
We asked our coding 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found after 
reviewing several pages of orders and a post op procedure report, there is no operative report and 
documentation of an EEG during non-intracranial surgery was found to support service billed. 
 
We looked at this coder's review, the file, and Medicare rules. 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 electroencephalogram (EEG) services provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services you 
received from June 23, 2020, through July 11, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that last year you 
had a hospital admission that was followed by an inpatient rehab stay and you were only charged one 
copayment. The Plan denied your request. The Plan says you had two separate admissions, so two copayments 
apply. 
 
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 
copayment per admission for inpatient services.  
 
Records show that you were admitted to an acute care hospital on June 12, 2020.  On June 23, you were 
discharged from the acute care hospital and admitted to an inpatient rehabilitation hospital. You have been 
asked to pay a $300 copayment for the inpatient rehabilitation services. Your Evidence of Coverage clearly 
states that if you are discharged and admitted to a different facility that you will be responsible for a separate 
copayment. 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 rehabilitation services you 
received from June 23, 2020, through July 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve below knee, molded socket, shin, sach foot, 
endoskeletal system (L5301), all lower extremity prostheses, flex foot system (L5980), and all lower extremity 
prostheses, multi-axial rotation unit ('mcp' or equal) (L5986). 
 
You asked the Plan to pre-approve the prostheses. You say that your current prosthesis is ill fitting of your 
socket. The Plan denied your request. The Plan says these items are not in disrepair and are still functioning at 
this time. 
 
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 prostheses have not been met. These items are not in disrepair 
and are still functioning at this time. Therefore, we decided that the Plan does not have to pre-approve below 
knee, molded socket, shin, sach foot, endoskeletal system (L5301), all lower extremity prostheses, flex foot 
system (L5980), and all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services provided. 
 
You asked the Plan to waive the copayments for chiropractic services. You say that you disagree with the way 
the claims were processed correctly. 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 chiropractic services.  
 
You received chiropractic services,for a total of 8 visits. Therefore, 
you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 8 
(chiropractic services) = $160.  
 
You have been asked to pay the total copayment amount of $160 for chiropractic services. Chiropractic 
services fall within the chiropractic services 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 chiropractic services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on November 
7, 2019. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this test has not been established as the standard of care for metastatic gastric cancer. 
 
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 pay for the test. Our reviewer says that the requested 
 
 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 
testing is only for non-small cell lung cancer patients and not for the enrollee's diagnosis of metastatic gastric 
cancer. The review has determined that the enrollee does not meet the criteria for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant360 test provided to the enrollee on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve titanium upgrade and seat cushion. 
 
You asked the Plan to pre-approve titanium upgrade and seat cushion. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that titanium upgrades are non-covered. Medicare 
rules also say that 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. 
 
We looked at the file and Medicare rules. Review of the file shows that titanium is already a covered material 
included in the code for the requested manual wheelchair. Also, the seat cushion is being denied due to a new 
and different seat being requested with a different code. The new code for a seat cushion was approved by the 
plan. Based on this information, we decided that Medicare rules for coverage of titanium upgrade and seat 
cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve titanium upgrade 
and seat cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) for tooth # 22, the extractions 
(D7140) for teeth # 23, 24, 25, 26, 27, and 28, and the immediate lower denture (D5140) provided on June 4, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you contacted the dental plan to find a provider 
that could do dentures. You say that you were never told that dentures were not covered. You also say that 
dentures should be covered since most people your age have dentures or partials. The Plan denied your request. 
The Plan says extractions are not listed as a covered service. The Plan says the immediate denture is not listed 
as a covered service either. The Plan also says that you did not sign up for any of the optional supplemental 
dental plans. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7210) for tooth # 22, the extractions (D7140) for teeth # 23, 24, 25, 26, 27, and 28, and the 
immediate lower denture (D5140) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RT300 FES cycle ergometer. 
 
You asked the Plan to pre-approve RT300 FES cycle ergometer. 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 follows Medicare rules. Medicare rules say that RT300 FES cycle ergometer (Neuromuscular 
Electrical Stimulation) is covered for certain indications only. 
 
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 RT300 FES cycle ergometer. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found you a diagnosis of C3-C6 primary quadriplegia after a motor vehicle 
accident from February 2020. The goal for the treatment is not indicated as ambulation but as improving 
strength. According to Medicare indications for use of a neuromuscular e-stim device is treatment of muscle 
atrophy.  Coverage of an NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where the 
nerve supply to the muscle is intact, including the brain, spinal cord and peripheral nerves and other non-
neurological reasons for disuse atrophy.  The indication must be for use for Walking in enrollees with Spinal 
Cord Injury (SCI). In this case, you have a spinal cord injury (SCI) that has resulted in quadriplegia. The use of 
this device is not intended for restoration of strength sufficient for ambulation. Therefore, you do 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 RT300 FES cycle ergometer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve RT300 FES cycle ergometer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on June 3, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you took your son to the ER and fell 
getting to your car. You feel that if you were allowed to wait with him in the waiting area this never would 
have happened. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER 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 ER visit provided on June 3, 
2020.  
 
We note your complaint that you were not allowed to wait with your son at the ER. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your husbands sugar was very low and 
called for the medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 15, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on June 11, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 nurse practitioner services provided on June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bladder irrigation procedure you had
 at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the bladder irrigation procedure. You say that you had to go to 
this facility because your doctor's office was closed due to COVID-19. The Plan denied your request. The Plan 
says you were charged this copayment correctly.  The plan says that because the allowed amount for this 
service ($248.58) is less than your copayment obligation, you are only being charged the allowed amount of 
$284.58. 
 
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 $295 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a $295 copayment for the bladder irrigation procedure. The bladder irrigation 
procedure falls within the surgery or other services provided at an outpatient hospital 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 procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 27, 2020 billed 
with code G0483. 
 
You asked the Plan to pay for the drug testing as billed. You say that this service was billed correctly and 
should be paid. The Plan denied your request. The Plan says the records do not support this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug testing, definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, review of the lab report 
shows only 20 billable drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the drug testing as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the definitive drug testing provided on April 27, 2020 billed with code G0483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0180, D1999) provided on June 26, 2020. 
 
You asked the Plan to pay for dental services. You say that a different provider at this office accepts your 
insurance. The Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
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. Therefore, we decided that the Plan does not have to pay for 
dental services (D0180, D1999) provided on June 26, 2020.