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

We decided that the Plan does not have to pay for a dental cleaning (D1110) provided September 12, 2019. 
 
You asked the Plan to pay for the dental cleaning. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services are only covered when performed by in-network providers. 
 
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. Dental services rendered by out-of-network providers are not covered. 
Therefore, we decided that the Plan does not have to pay for a dental cleaning (D1110) provided September 12, 
2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Valtrex provided on April 25, 2020. 
 
You asked the Plan to pay for Valtrex. You say that you were given a dose while in the ER. The Plan denied 
your request. The Plan says this drug is not covered under your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for Valtrex provided on April 25, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on 
February 24, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis 
(L3916) provided to the enrollee on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99201) and an application of 
electrical stimulation (97032) performed on April 30, 2020. 
 
You asked the Plan to pay for a chiropractic office visit and an application of electrical stimulation. You say 
that you were informed by a representative of the Plan that chiropractic services were covered with a $20 
copayment. The Plan denied your request. The Plan says the services you received are not Medicare-covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99201) and an application of electrical stimulation 
(97032) performed on April 30, 2020.  
 
Your complaint about receiving erroneous or misleading information from the Plan 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystography (74430) provided February 3, 2020. 
 
You asked the Plan to pay for the cystography. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the CPT code billed. 
 
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 74430 is cystography, minimum of 3 views, radiological 
supervision and interpretation. 
 
We find that CPT code 74430 is not supported in the medical record. Specifically, the records provided do not 
support that multiple views were obtained. The plan requested additional clinical documentation, but none was 
provided. Based on this information, we decided that Medicare rules for coverage of the cystography have not 
been met. Therefore, we decided that the Plan does not have to pay for a cystography (74430) provided 
February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex ultrasound provided on March 10, 
2020. 
 
You asked the Plan to waive the copayment for a duplex ultrasound. You say that you believe this should be a 
specialist copayment. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
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 $110 
copayment for each Medicare-covered diagnostic service, not including X-rays, performed in a physician's 
office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $91.17, which is less than your $110 copayment for a duplex ultrasound. A duplex 
ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for a duplex ultrasound provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 January 22, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance non-transport services provided on March 26, 
2020. 
 
You asked the Plan to pay for ambulance non-transport services. You say that you are requesting 
reimbursement of services rendered. 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 ambulance non-transport services have not been met. Per Medicare 
guidelines the Medicare ambulance benefit is a transportation benefit and without a transport there is no 
payable service. Per your plan benefit you are responsible for all paramedic intercept service costs that occur. Per review of the trip record received from the provider it shows that no transport 
took place. Therefore, we decided that the Plan does not have to pay for ambulance non-transport services 
provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on March 19, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on December 13, 2019, and December 
15, 2019. 
 
You asked the Plan to pay for the services provided. You say that the claim was denied in error. The Plan 
denied your request. The Plan says that the service exceeds the contracted maximum number of units by this 
provider. 
 
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. 
 
In this case, the CPT Code manual definition for code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient. We looked at the file and the rules. The rules say that a physician may 
only report one evaluation and management (E&M) code per day. The provided claim does not show that an 
E&M code was billed more than once for each date of service at issue. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the medical services provided on December 13, 2019, and 
December 15, 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 pay for CPT codes 97112 provided on January 23, 2020 and 97530 
provided on January 23, 2020, January 27, 2020, and January 30, 2020. 
 
You asked the Plan to pay for CT codes 97112 and 97530. 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. 
 
We looked at the file and Medicare rules. The file does not show that CPT code 97112 for date of service 
January 23, 2020 is supported in the medical records. The file does not show that CPT code 97530 for dates of 
service January 23, 2020, January 27, 2020, and January 30, 2020 is supported in the medical records. Based 
on this information, we decided that Medicare rules for coverage of CT codes 97112 and 97530 have not been 
met. Therefore, we decided that the Plan does not have to pay for CPT codes 97112 provided on January 23, 
2020 and 97530 provided on January 23, 2020, January 27, 2020, and January 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the compression system application provided on April 
9, 2020. 
 
You asked the Plan to waive the copayment for the compression system application. You say that nothing 
received on this day could be considered surgical only therapy. You say that the appropriate member 
responsibility is one copayment. The Plan denied your request. The Plan says that the copayments 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). The enrollee's contract with the Plan says that enrollees must pay a 
$25 copayment for each Medicare- covered occupational therapy visit.  
 
The Plan says the enrollee must pay a $30 copayment for the compression system application. Based on the 
plan contract, however, the enrollee cannot be asked to pay a separate copayment for the compression system 
application. The compression system application was done as part of a single occupational therapy visit under 
the plan of care. It would not be reasonable to assume that more than just the occupational therapy copayment 
would apply. Therefore, we decided that the Plan has to waive the copayment for the compression system 
application provided on April 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluorescein angiography services coded 92235 provided 
on December 4, 2019. 
 
You asked the Plan to pay for the fluorescein angiography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 92235 is fluorescein angiography (includes multiframe 
imaging) with interpretation and report, unilateral or bilateral. 
 
We find that CPT code 92235 is not supported in the medical record. Specifically, the documentation to 
support that images were obtained to support this code was not provided. Based on this information, we 
decided that Medicare rules for coverage of the fluorescein angiography services have not been met. Therefore, 
we decided that the Plan does not have to pay for the fluorescein angiography services coded 92235 provided 
on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on January 21, 
2020 and the unspecified adjunctive procedure (D9999) provided on May 13, 2020. 
 
You asked the Plan to pay for the upper partial denture (D5213) provided on January 21, 2020 and the 
unspecified adjunctive procedure (D9999). You say that you delayed the making of the partial plate until 2020 
assuming 50% would be covered. You say that your plan changed dramatically and the services were denied. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 upper 
partial denture (D5213) provided on January 21, 2020 and the unspecified adjunctive procedure (D9999) 
provided on May 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided March 
21, 2020 to April 19, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF 
services. The Plan denied your request. The Plan says medical necessity cannot be established for continued 
SNF level of coverage. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
 
 
 
 
 
 
 
 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided March 21, 2020 to April 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 3, 2020. 
 
You asked the Plan to pay for the physician's 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 
physicians 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 physician's services provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shaving of epidermal or dermal lesion, single lesion, trunk, 
arms or legs (11302) provided June 17, 2019. 
 
You asked the Plan to pay for shaving of epidermal or dermal lesion. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says there is insufficient 
documentation to corroborate the services to confirm that Medicare coverage has been met. 
 
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 11302 is shaving of epidermal or dermal lesion, single 
lesion, trunk, arms or legs. 
 
We find that CPT code 11302 is not supported in the medical record. Specifically, the medical records do not 
include a procedure note describing shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; 
lesion. Based on this information, we decided that Medicare rules for coverage of shaving of epidermal or 
dermal lesion have not been met. 
 
 Therefore, we decided that the Plan does not have to pay for shaving of epidermal or dermal lesion, single 
lesion, trunk, arms or legs (11302) provided June 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre test strips. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says the benefit does not cover diabetic supplies from a local or mail-order pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre test strips.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the compression system application provided on April 
13, 2020. 
 
You asked the Plan to waive the copayment for the compression system application. You say that nothing 
received on this day could be considered surgical only therapy. You say that the appropriate member 
responsibility is one copayment. The Plan denied your request. The Plan says that the copayments 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). The enrollee's contract with the Plan says that enrollees must pay a 
$25 copayment for each Medicare- covered occupational therapy visit. 
 
The Plan says the enrollee must pay a $30 copayment for the compression system application. Based on the 
plan contract, however, the enrollee cannot be asked to pay a copayment for the compression system 
application. The compression system application was done as part of a single occupational therapy visit under 
the plan of care. It would not be reasonable to assume that more than just the occupational therapy copayment 
would apply. Therefore, we decided that the Plan has to waive the copayment for the compression system 
application provided on April 13, 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.