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

 
We decided that the Plan does not have to pay for the crowns provided on April 25, 2019. 
 
You asked the Plan to pay for the crowns. You say that you could have used your remaining dental insurance 
benefit if you received a response sooner. You say that you should be reimbursed for out-of-pocket expenses. 
The Plan denied your request. The Plan says out-of-network dental services are 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
crowns provided on April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable


We decided that the Plan does not have to waive the coinsurance for a wheelchair (K0824, E1028, E2601) provided February 29, 2020.

You asked the Plan to waive the coinsurance for the wheelchair. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. 

You have been asked to pay a 20% coinsurance ($181.77) for the wheelchair. The wheelchair falls within the durable medical equipment 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 a wheelchair (K0824, E1028, E2601) provided February 29, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that step therapy requirements were not followed. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable or necessary. Our physician reviewer found in this case, the enrollee has 
x-ray evidence of a partial compression fracture of T12 - age indeterminate. The requested Prolia is therefore 
medically necessary. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual drug assays billed for testing provided on 
February 1, 2020. 
 
You asked the Plan to pay for the drug assays. You say that the testing should be paid in full. The Plan denied 
your request. The Plan says these codes are for blood testing and no blood sample was received. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the codes billed in this case are not supported as they describe testing that requires a plasma/serum 
sample. The documentation shows that a urine sample only was received. Based on this information, we 
decided that Medicare rules for coverage of the drug assays have not been met. Therefore, we decided that the 
Plan does not have to pay for the individual drug assays billed for testing provided on February 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the charges for the incisional biopsies and debridement 
provided on March 3, 2020 and March 10, 2020. 
 
You asked the Plan to reduce the charges for the biopsy and related procedures. You say that you believe that 
this copayment is too high for a skin biopsy with no stitches required. The Plan denied your request. The Plan 
says you received an outpatient surgery in the hospital setting. The $350 copayment was correctly applied to 
each date. 
 
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 $350 
copayment for outpatient surgery provided in a hospital facility.  
 
You have been asked to pay $700 for both dates on which these services were received. The biopsy and related 
procedures fall within the outpatient surgery provided in a hospital facility 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 reduce the charges for the incisional biopsies and debridement provided on March 3, 2020 and 
March 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided June 21, 2019 to 
June 30, 2019. 
 
You asked the Plan to pay for the Skilled Nursing Facility Services. You say that SNF services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria was not met. 
 
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 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 Skilled Nursing Facility Services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
Services could be provided at a 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 the Skilled Nursing Facility Services have not been met. Therefore, we decided 
that the Plan does not have to pay for Skilled Nursing Facility services provided June 21, 2019 to June 30, 
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug panels (80307 and 
G0483) and the individual therapeutic drug assays provided on January 21, 2020. 
 
You asked the Plan to pay for the lab testing. You say that this should be covered. The Plan denied your 
request. The Plan says there is no valid order and invalid codes were billed for urine testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that lab testing may be 
covered only when ordered by a treating provider.  
 
In this case, the documentation includes an order for a Chronic care Management Profile. There is no 
itemization of the drug classes tested in this panel to confirm the intent for the billed testing. In addition, the 
individual drug assays are not supported as coded. These codes describe testing done on a plasma or serum 
sample and no plasma or serum sample was used in this case. Therefore, we decided that the Plan does not 
have to pay for the presumptive and definitive drug panels (80307 and G0483) and the individual therapeutic 
drug assays provided on January 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for removals of cataracts with insertion of 
lens (66984) performed on February 25 and March 19, 2020. 
 
You asked the Plan to waive the copayments for removals of cataracts with insertion of lens. You say that you 
were not quoted these charges prior to the surgery. 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 $350 
copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center.  
 
You have been asked to pay $700 or two $350 copayments for two removals of cataracts with insertion of lens. 
Removal of cataracts with insertion of lens falls within the "Outpatient Surgery and Other Medical 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 copayments for removals of cataracts with insertion of lens (66984) performed on 
February 25 and March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen therapy (G0277) and blood glucose 
testing (82962) provided on March 5, 2020. 
 
You asked the Plan to pay for the hyperbaric oxygen therapy and blood glucose testing. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says both 
82962 and G0277 processed with a status indicator of N, which is for bundled services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes G0277 and 82962 are not supported in the record. Specifically, the Plan paid for the 
code with the J1 status indicator (11044). One of the denied codes (82962) has a status indicator of Q4, 
indicating it is a packaged service when billed with a code that has a J1 status indicator. The other denied code 
(G0277) has a status indicator of S, which per above is packaged into the J1 procedure code. Based on this 
information, we decided that Medicare rules for coverage of the hyperbaric oxygen therapy and blood glucose 
testing have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen 
therapy (G0277) and blood glucose testing (82962) provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 a seat lift mechanism. Our reviewer 
says that the documentation does not support that the requested seat lift mechanism is medically reasonable or 
necessary. Our physician reviewer found the enrollee is able to ambulate with a walker. The documentation 
does not reveal objective evidence that the patient has severe arthritis of the hip. The documentation does not 
reveal that the enrollee has a neuromuscular disease. The documentation does not support that a seat lift is 
likely to affect improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's 
condition. The records do not indicate that the enrollee is completely incapable of standing from a chair in the 
home on a physical exam. Therefore, the enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy treatment services billed for date of 
service December 3, 2019. 
 
You asked the Plan to pay for the chemotherapy. You say that records were provided to support payment. The 
Plan denied your request. The Plan says there is no documentation of the billed services being rendered. 
 
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 codes billed are not supported in the medical record. Specifically, the record for this date 
documents only an office visit. There is notation of prior chemotherapy and planned future chemotherapy but 
no documentation of any drugs being administered on this date. Based on this information, we decided that 
Medicare rules for coverage of the chemotherapy have not been met. Therefore, we decided that the Plan does 
not have to pay for the chemotherapy treatment services billed for date of service December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary to 
provide a diagnosis to the patient's referring physician. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered.  Neither you nor the referring physician are plan providers. 
 
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 May 19, 2020 by 
an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 16, 2020 to 
February 19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that none of the providers on the Plan's approved 
provider list would provide home health aide services in the enrollee's area. 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 is not enrolled in the Medicare program. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules also say 
that a provider must be enrolled in the Medicare program to be eligible for payment. 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. This provider is not enrolled in the Medicare program. 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 February 16, 2020 to February 19, 2020 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral formula (B4150) and syringes (A4213) provided on 
November 24, 2019. 
 
You asked the Plan to pay for the enteral formula and syringes. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not include an itemized shipping invoice or a proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery for any of the supplies or a physician order for the syringes. . 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for enteral formula (B4150) and syringes (A4213) 
provided on November 24, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the oral surgery evaluation and imaging provided on August 12, 2019 
and August 14, 2019. 
 
You asked the Plan to pay for the oral surgery evaluation and imaging. You say that this should be covered by 
Medicare. The Plan denied your request. The Plan says that these are dental services and are excluded from 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that dental services are not covered. 
 
In this case, the enrollee presented for evaluation of pain in the upper jaw and was found to have a lesion that 
has caused maxillary bone fracture. These services are not related to the care, treatment, fillings, removal, or 
replacement of teeth or supporting structures. This is evaluation and management of a medical condition. The 
plan's denial due to dental coverage exclusion is not supported. Therefore, we decided that the Plan has to pay 
for the oral surgery evaluation and imaging provided on August 12, 2019 and August 14, 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 pay for Carbamazepine (80157),  Levetiracetam (80177), 
Topiramate (80201),  Digoxin (80162), Clozapine (80159) and Haloperidol (80173) with blood sampling 
provided on December 13, 2019. 
 
You asked the Plan to pay for the plasma/serum testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the services billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 plasma/serum testing. Our reviewer says 
that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 do not meet criteria for billing or 
reimbursement consideration. Our physician reviewer found the laboratory report states that a urine sample was 
collected. Therapeutic Drug Assays are performed to monitor clinical response to a known, prescribed 
medication.  The material for examination is whole blood, serum, plasma, or cerebrospinal fluid. 
 
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 plasma/serum testing have not been met. Therefore, we decided that the 
Plan does not have to pay for Carbamazepine (80157),  Levetiracetam (80177), Topiramate (80201),  Digoxin 
(80162), Clozapine (80159) and Haloperidol (80173) with blood sampling provided on December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 26, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that it is difficult to get prior authorization for 
nursing home patients. The Plan denied your request. The Plan says unauthorized, non-plan care is not a 
covered benefit. 
 
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 31, 2020 
an out of network (OON) provider.
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 
September 18, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the final claim was not submitted within the 
required time. 
 
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. 
 
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, the record 
does not indicate that a final claim was submitted within the allowable time frame. Therefore, we decided that 
the Plan does not have to pay for the home health services provided to the enrollee from September 18, 2019.