Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the knee orthosis (LT)  (L1833) and suspension sleeve (LT) (L2397) 
and does not have to pay for the knee orthosis (RT) (L1833) and suspension sleeve (RT) (L2397). We decided 
that the Plan does not have to pay for the knee orthosis (RT) (L1833) and suspension sleeve (RT) (L2397).  
 
You asked the Plan to pay for the knee orthosis (LT)  (L1833) and suspension sleeve (LT) (L2397) and does 
not have to pay for the knee orthosis (RT) (L1833) and suspension sleeve (RT) (L2397). You say that the 
enrollee needs the knee braces as a necessity for treating long term osteoarthritis, gout arthropathy. She has 
tried numerous therapies with little relieve. The Plan says that the medical records do not support the billed 
service. 
 
We decided that the Plan has to pay for the knee orthosis (LT)  (L1833) and suspension sleeve (LT) (L2397) 
and does not have to pay for the knee orthosis (RT) (L1833) and suspension sleeve (RT) (L2397).  
 
We also decided that the Plan does not have to pay for the knee orthosis (RT) (L1833) and suspension 
sleeve (RT) (L2397). 
 
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 orthoses. Our reviewer says that this 
enrollee partially meets the Medicare criteria for the requested orthoses. Our physician reviewer found Based 
on the medical records provided (an orthopedic visit note dated 12/06/2018) there is documentation that meets 
the requirements listed in the Local Coverage Determination (LCD): Knee Orthoses (L33318) for Medicare 
coverage of the left knee orthosis. Valgus laxity of the left knee is documented in the setting of primary 
osteoarthritis. No joint laxity of other qualifying condition is documented for the right knee. The enrollee meets 
criteria for the knee orthosis for the left knee but not the right knee. 
 
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 orthoses have partially been met. Therefore, we decided that the Plan has to 
pay for the knee orthosis (LT)  (L1833) and suspension sleeve (LT) (L2397) and does not have to pay for the 
knee orthosis (RT) (L1833) and suspension sleeve (RT) (L2397).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic devices (L3916, L3960, L0650, L1851) provided 
May 1, 2020. 
 
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the telehealth consult utilized to prescribe these devices does not meet 
Medicare requirements. 
 
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. The records do not show any existing relationship between the prescribing 
physician and the enrollee, or contact between the prescribing telehealth physician and the enrollee's local 
physician. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. 
Therefore, we decided that the Plan does not have to pay for orthotic devices (L3916, L3960, L0650, L1851) 
provided May 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PET Scan (78815) provided on February 10, 2020. 
 
You asked the Plan to pay for the PET. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was not reported with an appropriate 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET have not been met. Specifically, the Medicare Claims Processing Manual, Chapter 13, 
60.16 includes a list of appropriate diagnosis codes. D3A.020 is not included on this list of appropriate codes. 
Therefore, we decided that the Plan does not have to pay for a PET Scan (78815) provided on February 10, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service (11042) rendered by the out of 
network (OON) provider on September 26, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee 
on January 24, 2020. 
 
You asked the Plan to pay for non-emergent ambulance services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 non-emergent ambulance services have not been met. A 
physician's or podiatrist office / clinic / outpatient center is not a covered destination. Therefore, we decided 
that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on January 24, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 24, 2020. 
 
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 screening tests are 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 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 laboratory 
services rendered on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and the referring provider is also out-of-network with the Plan. 
 
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 medical services provided on March 13, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you had on May 26, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were told that if you went to 
an in-network provider, there would be no copayment. The Plan denied your request. The Plan says a $20 
copayment applies to lab services. 
 
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 Medicare-covered lab tests.  
 
You have been asked to pay a $20 copayment for the lab 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 the lab services you had on May 26, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Decipher prostate biopsy testing provided on October 24, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to guide them through the process of selecting appropriate treatment. The Plan denied your request. The Plan 
says that the denial of payment for this testing is correct, because this testing did not meet the clinical criteria 
for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice that this testing would not 
be covered. Without this information, we cannot determine whether the lab order made constituted plan-
directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for Decipher prostate biopsy 
testing provided on October 24, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic mammography (77066) and a 
digital breast tomosynthesis (G0279) performed on May 21, 2020. 
 
You asked the Plan to waive the deductible for a diagnostic mammography and a digital breast tomosynthesis. 
You say that you should not have to pay this amount for your yearly preventive mammogram. 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. Your 
contract with the Plan says that there is a $750 deductible that applies to basic imaging services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category "Outpatient 
diagnostic tests and therapeutic services and supplies." The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible that applies to basic imaging services. This cost 
sharing is a contractual obligation that had not been met at the time a diagnostic mammography and a digital 
breast tomosynthesis were performed on May 21, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for a diagnostic mammography (77066) and a digital breast tomosynthesis (G0279) 
performed on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer. 
 
You asked the Plan to pre-approve the labial veneer. You say that the Plan representative that sold you this 
dental policy told you that this dental work would be covered. The Plan denied your request. The Plan says this 
service is not covered. 
 
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 a 
labial veneer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on April 20, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 nursing facility care (99309) provided on April 
20, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

  
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) on 
February 13, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that your emergency room 
visit was caused by your involvement in a hit-and-run accident and that the other party in the accident should 
be held liable for the copayment. The Plan denied your request. The Plan says 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 $90 
copayment for each emergency room visit.  
 
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 (99284) on February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on January 24, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says he 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 
diagnostic radiology 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 diagnostic radiology services provided on January 
24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic CGM, includes all supplies 
and accessories, 1 month supply = 1 unit of service (CPT Code K0553) provided on January 20, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 services have not been met. Healthcare Common Procedure 
Coding System (HCPCS) code K0553 KF KX CG (1 Unit) remains not supported. Documentation submitted 
did not support the diagnosis used on the submitted order, nor did the documentation indicate the provider 
discussed the need for the billed supply code; therefore, the billed supply code cannot be verified.  It is noted, 
multiple attempts were made to obtain additional information from the provider. 
 
 
Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic CGM, includes 
all supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) provided on January 20, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0426) received 
on May 21, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you refuse to pay for 
ambulance services which were excessively tardy. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 a $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these 
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 the ambulance services (A0426) received on 
May 21, 2020.  
 
Your complaint about the ambulance services being excessively tardy is not a valid appeal for medical 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0428) received 
on February 17, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford to pay 
this charge. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $220 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $220 for these 
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 the ambulance services (A0428) received on 
February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on February 21, 
2020. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee transferred to acute care on February 21, 
2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the skilled nursing facility services have not been met. The enrollee was discharged from the 
facility on February 21, 2020. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility services provided on February 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says authorization for 
these services was required but 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 did not pre-approve the 
item/service at issue. Additionally, medical records have been requested, but none were received. There is 
insufficient documentation to verify whether payment is due and the amount of payment. 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 medical services provided on March 17, 2020 by an out of network (OON) provider.