Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on October 23, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on October 23, 2019.  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 31, 
2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness exam 
and you should not owe a copayment. 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 $10 
copayment for physician/practitioner services, including doctor?s office visits.  
 
The medical records show that you received services beyond an annual wellness exam on August 31, 2020. 
Therefore, you are responsible to pay the $10 copayment.  
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64636, 64635). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is the most effective treatment for 
you. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only when dual medial branch blocks provide 
greater than 80% relief of the primary or index pain and duration of relief is consistent with the agent employed 
may facet joint denervation with radiofrequency medial branch neurotomy be considered. 
 
We looked at the file and Medicare rules. The medical record does not show that medial branch blocks 
provided at least 80% pain relief. Based on this information, we decided that Medicare rules for coverage of 
radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (64636, 64635).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable home oxygen supplementation. 
 
You asked the Plan to pre-approve portable home oxygen supplementation. You say that the claim should be 
paid. The Plan denied your request. The Plan says the enrollee did not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable home oxygen supplementation. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the lack 
of supportive information including ABG or pulse oximetry results, the criteria has not been met. There was 
insufficient objective information provided to clearly support the use of the portable oxygen at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable home oxygen supplementation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve portable home oxygen supplementation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 23, 2020, to March 26, 2020. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed on the correct form. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. The rules also say that institutional providers, 
including home health agencies, use one of two institutional claim formats, the 837 institutional claim or the 
paper Form CMS-1450, also known as the UB-04. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was billed on form CMS-1500. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from March 23, 2020, to March 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on July 17, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you should only owe $947.03 
and the Plan should owe the rest. 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 $1,000 
deductible. Your contract with the Plan also clearly says that after the $1,000 deductible has been met, 
enrollee's must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers. 
 
You received a cataract surgery on July 17, 2020. The record shows that you had paid $52.97 toward the 
$1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining 
deductible balance of $947.03. Now that the $1,000 deductible has been met, you are also responsible to pay 
$27.97, which is less than the $250 copayment.  
 
The total amount you owe is: $947.03 + $27.97 = $975.  
 
You have been asked to pay the total amount of $975 for cataract surgery. Cataract 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 cataract surgery provided on July 
17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. 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. 
 
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 skilled nursing services provided on February 11, 
2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for bioimpedance spectroscopy (BIS), extracellular fluid analysis (93702) 
provided on January 27, 2020. 
 
You asked the Plan to pay for the lymphatic mapping. You say that you would like reconsideration because the 
records support the service billed The Plan denied your request. The Plan says that this service was not 
medically necessary. 
 
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 pay for the lymphatic mapping. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered the gold standard imaging modality for the diagnostic imaging of the of 
lymphatic flow disorders such as lymphedema. 
 
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 lymphatic mapping have been met. Therefore, we decided that the Plan has 
to pay for bioimpedance spectroscopy (BIS), extracellular fluid analysis (93702) provided on January 27, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the personal care services (T1019). 
 
You asked the Plan to pre-approve the personal care services. You say that these services are necessary for 
your condition. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. Custodial care services are not 
covered. 
 
We looked at the file and Medicare rules. The services you are requesting are custodial care services which are 
not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
personal care services (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on April 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. 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. The 
Plan says that the member's primary care physician did not refer 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 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 specialist services provided on April 13, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on July 30, 2020. 
 
You asked the Plan to pay for CPT code 70450. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 70450 
has a bundled relationship with code 70496 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 the CT scan (70450) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the high gold content crown (D2790) 
provided on July 19, 2020. 
 
You asked the Plan to waive the copayment for the dental service. You say that you were advised by a plan 
representative that there was a $0 copayment for the crown. The Plan denied your request. The Plan says the 
cost share was assessed correctly. The Plan says there is a $125 copayment for crowns. 
 
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, there is a $125 copayment for the 
crown. This is a contractual obligation you agreed to when you enrolled in the Plan?s dental coverage. 
Therefore, we decided that the Plan does not have to waive the copayment for the high gold content crown 
(D2790) provided on July 19, 2020.  
 
Your complaint about receiving misinformation from a plan representative is not a valid appeal for dental 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on June 22, 
2020. 
 
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status 
indicator of I and is not valid for Medicare purposes. 
 
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 CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means that CPT code 77062 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have 
not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) 
provided on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 21, 2019. 
 
You asked the Plan to pay for the services provided. You say that your illness has been difficult to treat. The 
Plan denied your request. The Plan says the testing was not required for treatment or management of your 
generalized anxiety disorder. 
 
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. 
 
We looked at the file and the rules. In this case, there is insufficient medical records to show the results of this 
testing will be used to determine a specific treatment strategy. 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 the lab services provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace provided on June 22, 2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that the brace didn't fit properly but 
you couldn't return it. The Plan denied your request. The Plan says the coinsurance applied 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% of 
the cost for each Medicare-covered item.  
 
You have been asked to pay $274.24, which is 20% of the allowed amount for the back brace. The allowed 
amount is $1.371.22 (20% x $1.371.22 = $274.24). The back brace falls within the "Prosthetic devices 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 the back brace 
provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
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 physician services provided by 
an out of network (OON) provider.