Persius/hicric huggingface dataset:
Appeal type: Lab
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 these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 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 17, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0230, D2799, D2999, and D9215) 
provided on July 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services are not covered by the Plan's 
supplemental 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, 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 dental 
services (D0230, D2799, D2999, and D9215) provided on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Digoxin 250 mcg tablet. 
 
You asked the Plan to pre-approve Digoxin. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the member's Plan has Part A and Part B coverage, with no Part D drug coverage. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Digoxin have not been met. Specifically, Digoxin is a Medicare Part D drug and is not covered 
under Part B. Therefore, we decided that the Plan does not have to pre-approve Digoxin 250 mcg tablet.  
 
Benefits for Digoxin may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on July 3, 2019. 
 
You asked the Plan to pay for the diagnostic radiology 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 
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 July 3, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device with sleeves provided on 
July 27, 2020. 
 
You asked the Plan to pay for pneumatic compression device. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because 
these items do not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0651 
is only covered following a failed six-month trial of conservative therapy as described in the previous section.  
 
We looked at the file and Medicare rules. The documentation submitted does not show that the enrollee failed a 
six-month trial of conservative therapy meeting all of the Medicare requirements. Based on this information, 
we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, 
we decided that the Plan does not have to pay for a pneumatic compression device with sleeves provided on 
July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee scooter provided from June 4, 2020 to July 14, 2020.You asked the Plan to pay forthe knee scooter. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the item received is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that knee scooters (crutch substitutes) are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met.Therefore, we decided that the Plan does not have to pay forthe knee scooter provided from June 4, 2020 to July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
July 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by 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 July 5, 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 July 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the 3 additional 
periapical x-rays (D0230), and the comprehensive periodontal evaluation (D0180) provided on February 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you refuse to pay this bill. You say that you 
were advised by a plan representative that this provider was in network. You also say that you should not be 
responsible for the plan representative's mistake. The Plan denied your request. The Plan says you must receive 
your care from a network provider. The Plan says that the provider in this case is not a network provider. 
 
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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-
ray (D0220), the 3 additional periapical x-rays (D0230), and the comprehensive periodontal evaluation 
(D0180) provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography (77067) provided. 
 
You asked the Plan to pay for the screening mammography. You say that you would like reconsideration 
because the member had multiple exams on the same date of service. The Plan denied your request. The Plan 
says a claim for this service was previously processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening mammography have not been met. Specifically, the record indicates that a claim for 
CPT code 77067 billed by the same provider was previously processed and paid. The clinical information 
submitted does not show that more than one screening mammography was performed on the billed date of 
service. Therefore, we decided that the Plan does not have to pay for the screening mammography (77067) 
provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions in hospital settings. 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says this service is not covered by Medicare or your Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental extractions in 
hospital settings.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on June 25, 2020. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that this should be covered. 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 ConfirmMDx is covered when the enrollee has 
undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat 
biopsy due to persistent or elevated cancer-risk factors. 
 
 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee had a 
previous cancer-negative prostate biopsy within 24 months and was being considered for a repeat biopsy due to 
persistent or elevated cancer-risk factors. Based on this information, we decided that Medicare rules for 
coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay 
for ConfirmMDx testing (81551) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dermatology services provided on July 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe dermatology services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of network provider.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 areaurgent 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 forthe dermatology services provided on July 8, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve personal care services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say custodial care is not covered. 
 
We looked at the file and Medicare rules. In this case, the personal care services you are requesting are 
considered custodial care based on Medicare guidelines. Custodial care includes care that helps people with 
activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, 
and supervision of special diets and medications. Custodial care is not covered under Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve personal care services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded A0429 provided on November 
14, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 A0429 is Ambulance service, basic life support, 
emergency transport (bls-emergency). 
 
We find that CPT code A0429 is not supported in the medical record. Specifically, this code was billed with 
modifier QL (Patient pronounced dead after ambulance called). This modifier with this procedure code is not 
reimbursable. Based on this information, we decided that Medicare rules for coverage of the ambulance 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
services coded A0429 provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home blood glucose monitor rendered on June 3, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the home blood glucose monitor rendered on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on March 12, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1833). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the 
Proof of Delivery did not include details to corroborate the Delivery Ticket. 
 
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 valid proof of delivery for the supplies provided in this case. There is no itemized 
delivery ticket or itemized shipping invoice in the file. 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 the knee orthosis provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 29, 2019 by an 
out of network (OON) provider. 
 
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 the services were 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant/abutment supported removable denture for 
edentulous arch-mandibular (D6111). 
 
You asked the Plan to pre-approve dental code D6111. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says this service is not covered when the enrollee's dental 
implants were not originally placed by a participating provider. 
 
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 when the enrollee's dental implants were not originally placed by a 
participating provider. Therefore, we decided that the Plan does not have to pre-approve implant/abutment 
supported removable denture for edentulous arch-mandibular (D6111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 10, 2020, by an 
OON provider. 
 
You asked the Plan to pay for nursing facility care. You say that the Plan has the responsibility to pay for the 
service rendered to the enrollee. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
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 February 10, 
2020, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by 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. 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ultrasound provided on August 14, 
2020. 
 
You asked the Plan to waive the coinsurance for the ultrasound. You say that you already paid a $15 
copayment. You say that insurance should have paid the entire cost. 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% 
coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. 
 
You have been asked to pay $18.47, which is 20% of the allowed amount for the ultrasound. The allowed 
amount is $92.33 (20% x $92.33 = $18.47). The ultrasound falls within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate 
service. 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 ultrasound provided on August 14, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Kanjinti provided from July 9, 2020, to August 20, 2020.
You asked the Plan to pay for Kanjinti. You say that this was medically necessary. The Plan denied your request. The Plan says that this is not supported for your diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Kanjinti. Our reviewer says that the criteria for coverage of Kanjinti have been met. Our physician reviewer found the use of Kanjinti is FDA-approved for your diagnosis and is supported by one of the major drug compendia or by clinical research. The documentation support that this drug was safe, effective, and otherwise reasonable and necessary for you in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kanjinti have been met. Therefore, we decided that the Plan has to pay for Kanjinti provided from July 9, 2020, to August 20, 2020.