Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on May 7, 2020. 
 
You asked the Plan to pay for the ophthalmology 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmology services provided on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral 
periapical x-ray, topical application of fluoride, excluding varnish, and periodontal maintenance provided on 
June 2, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays, topical application of fluoride, and periodontal 
maintenance. You say that you were charged $184 for a 6 month dental cleaning. You also say that you did not 
receive a dental cleaning like they normally do because of COVID-19. The Plan denied your request. The Plan 
says these services are non-covered under your routine dental 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 first 
intraoral periapical x-ray, additional intraoral periapical x-ray, topical application of fluoride, excluding 
varnish, and periodontal maintenance provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost sharing forallergy injections you received on March 9, 2020.You asked the Plan to waive the cost sharing forthe allergy injections. You say that there should be no copayment for this service.The Plan denied your request. The Plan did not provide an argument.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.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the case file that the Plan submitted to us was substantially deficient. It is difficult to even discern what this case involved. The Plan failed to provide any documentation supporting this case including Notices of Denial, Explanations of Benefits, or even any explanations of how cost sharing was applied. The Plan has not explained which category of cost sharing from their Evidence of Coverage they applied to this claim. Without that, we cannot determine if the Plan processed this claim appropriately. It is the Plan's obligation to substantiate cost sharing charged and they have failed to do so in this case. Therefore, we decided that the Plan has to waive the cost sharing forallergy injections you received on March 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 chiropractic services provided from February 1, 2020 to 
February 26, 2020. 
 
You asked the Plan to pay for chiropractic services. You say that you were told you could go out of network. 
The Plan denied your request. The Plan says this is not 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.  
 
We looked at the file and Medicare rules. The submitted medical records do not document the presence of s 
subluxation. Based on this information, we decided that Medicare rules for coverage of chiropractic services 
have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic services provided 
from February 1, 2020 to February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided from April 15, 2020 
to May 15, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that the neuromuscular 
stimulator was medically necessary. The Plan denied your request. The Plan says the reasonableness of the 
durable medical equipment was not established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 neuromuscular stimulator (E0745). Our 
reviewer says that the requested items were not considered medically reasonable and necessary in this case. 
Our physician reviewer found coverage of Neuromuscular Electrical Stimulation to treat muscle atrophy is 
limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be 
casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement 
surgery (until orthotic training begins). The documentation does not support that the coverage criteria have 
been met 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 the neuromuscular stimulator (E0745) have not been met. Therefore, we 
decided that the Plan does not have to pay for the neuromuscular stimulator provided from April 15, 2020 to 
May 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
January 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that these services were 
provided due to medical necessity. The Plan denied your request. The Plan says these services were rendered 
by a non-contracted provider. The Plan also says that the services were 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 ambulance service and ground mileage 
provided on January 6, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ECG tracing provided on September 23, 2019 by an 
OON provider. 
 
You asked the Plan to pay for the ECG tracing. You say that this service was a medical service provided in a 
medical setting, and should be processed under the medical insurance policy. The Plan denied your request. 
The Plan says the service was rendered by a non-network provider. The Plan also says that the enrollee was 
referred by another non-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 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 ECG tracing provided on September 23, 2019 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durolane injection provided on September 20, 2019. 
 
You asked the Plan to pay for the durolane injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed do not support the units 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. 
 
We find that CPT code J7318 is not supported in the medical record. Specifically, 120 units were billed of this 
service. The documentation does not support the units billed. Based on this information, we decided that 
Medicare rules for coverage of the durolane injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the durolane injection provided on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xT panel testing provided to the enrollee on 
March 17, 2020. 
 
You asked the Plan to pay for this testing. You say that this testing was medically necessary and should be 
covered by the Plan. The Plan denied your request. The Plan says Medicare covers next generation sequencing 
for cancer only when certain criteria are met.  
 
 
The Plan says that the requested service, Tempus xT gene panel, does not have FDA approval and has not 
completed a technical assessment required for Medicare coverage. In addition, Medicare guidelines for billing 
a panel test were not met.  
 
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 rules say this type of testing has specific coverage and billing criteria 
that must be met for cover. The test at issue in this appeal appears to have been requested for screening 
purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does 
not have to pay for Tempus xT panel testing provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you feel that the 
charges are too high. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
You have been asked to pay 20% coinsurance for DME and related supplies. DME and related supplies falls 
within the DME and related supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
DME and related supplies provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on January 15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation?) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 
1, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appeals from the provider reveal a consistent pattern of unsolicited contact and no physical 
exam. 
 
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 durable medical equipment 
provided to the enrollee on May 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic mammograms provided. 
 
You asked the Plan to waive the deductible for diagnostic mammograms. You say that you disagree with the 
charges and feel that the services should be a covered benefit. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient hospital services.  
 
You received diagnostic mammograms. The record shows that you had paid $0 toward the 
$750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount 
of $217.08.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at 
the time diagnostic mammograms were receive. Therefore, we decided that the Plan does not have to waive the 
deductible for diagnostic mammograms provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on June 10, 2020. 
 
You asked the Plan to pay for the eye exam. You say that you were not aware that you had received a previous 
eye exam inside of 12 months and you would have waited the required time if you had known. The Plan denied 
your request. The Plan says you have already received the maximum amount of coverage allowed for this type 
of service. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services for one routine eye exam every 12 months. 
 
We looked at the file and the Plan's rules. The file shows that received a routine eye exam from the same 
provider on July 19, 2019. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on 
June 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises and manual therapy techniques 
provided on January 21, 2020 by an OON provider. 
 
You asked the Plan to pay for the therapeutic exercises and manual therapy techniques. You say that the 
enrollee was referred by an in-network provider. You also say that the services were provided in good faith, 
and were medically necessary. The Plan denied your request. The Plan says these services were rendered by a 
non-network provider. The Plan also says that the enrollee was referred by another non-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 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 therapeutic exercises and manual therapy 
techniques provided on January 21, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided 
 by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that the services were 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 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 ambulance service and ground mileage 
provided on January 21, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on October 2, 2019. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the 
hearing benefit is not covered if the hearing aids are not ordered through the designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only with the designated vendor. 
 
We looked the file and the Plan's rules. The hearing aids were provided by a provider that is not a designated 
hearing aid provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
hearing aids provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a special breathing machine (CPT Code 
A4604 x 1 per 3 months, A7030 x 1 per 3 months, A7031 x 1 per 1 month, A7035 x 1 per 6 months, A7036 x 1 
per 6 months, A7038 x 2 per 1 month, A7039 x 1 per 6 months and A7046 x 1 per 6 months). 
 
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the clinical information shows that you had a need for CPAP but there 
is no recent office visits with update information on your current condition. 
 
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 DME. Our physician reviewer 
found you have a long history of obstructive sleep apnea (OSA), and have been on BiPAP since 2004. You are 
requesting new supplies for the BiPAP. The most recent clinical visit is from September 12, 2018. An updated 
clinical evaluation is needed with a compliance download. If you are using the device and continuing to benefit 
from it, another sleep study is not necessary. Pending a more recent clinical evaluation, the BiPAP supplies are 
considered not medically  necessary, and the denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve supplies for a special breathing machine (CPT Code A4604 x 1 per 3 months, A7030 x 1 per 3 
months, A7031 x 1 per 1 month, A7035 x 1 per 6 months, A7036 x 1 per 6 months, A7038 x 2 per 1 month, 
A7039 x 1 per 6 months and A7046 x 1 per 6 months).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stationary oxygen system purchased, from an 
out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee's primary care physician indicated that 
they required oxygen but no prescription was processed and it was after hours. The Plan denied your request. 
The Plan says this provider is not in-network and there are services available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the stationary oxygen system purchased, from an out-of-network provider.