Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound services you had on March 
3, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound services. You say that you should only have to 
pay a $30 copayment since this ultrasound was performed in an office setting. The Plan denied your request. 
The Plan says this cost sharing was 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 a $155 
copayment for Medicare-covered diagnostic radiological services performed in a physician?s office. This 
includes ultrasounds. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound services you had 
on March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 18, 2020 to 
March 20, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that the Plan should 
cover these medications. The Plan denied your request. The Plan says payment for these medications must be 
submitted to Medicare Part D. 
 
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 self-administered drugs provided 
from March 18, 2020 to March 20, 2020.  
 
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on February 19, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that this provider did not resolve your issue, and made multiple mistakes in submitting this claim. You 
also say that the provider did not check your benefits, or inform you of the services prior to rendering them, 
and you believe they should be covered. The Plan denied your request. The Plan says these services are not 
covered. The Plan also says that you did not enroll in a supplemental dental benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
February 19, 2020.  
 
Your complaint about your issues with this dental provider 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on May 11, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that this claim falls under very specific Medicare 
guidelines for medical necessity and should be recognized as such. The Plan denied your request. The Plan says 
the denial of payment for this item is correct, because the documentation submitted does not include a valid 
order, proof of delivery, or progress notes to support the item billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order must be completed for 
coverage of a lumbar-sacral orthosis with code L0648.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid standard 
written order for this item. Namely, the order form submitted does not include a general description of the 
specific item billed on this claim. Based on this information, we decided that Medicare rules for coverage of 
lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis provided on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses and frames provided on December 6, 
2019. 
 
You asked the Plan to pay for the progressive lenses and frames. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the progressive lenses and frames provided on December 6, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve an electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness. You say that the items are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
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 pre-approve an electrical connection between the 
wheelchair controller and two or more motors, expandable controller, and harness. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the electrical connection 
between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness 
(E2313) at issue in this case are medically reasonable and necessary. Records do not document that the enrollee 
has upper extremity weakness such that she cannot control the power options using their own switches which 
are included in the allowance of these power options. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electrical connection between the wheelchair controller and two or more motors 
(E2311), expandable controller (E2377) and harness (E2313).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on February 26, 2020. 
 
You asked the Plan to pay for the imaging services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the imaging services provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis and electrical stimulator supplies 
provided on March 24, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis (L3916) and electrical stimulator supplies (A4595). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed supply codes 
cannot be verified. 
 
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. The invoice 
submitted has a date of service of May 11, 2020 with contents- wrist hand orthosis, description- supplies, 
number of pieces-1. The date of service and shipping date have a significant variation. 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 wrist hand orthosis and electrical stimulator supplies provided on 
March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP vaccine provided to the enrollee on March 5, 2020. 
 
You asked the Plan to pay for vaccines under Medicare Part B. You say that this claim should be paid. The 
Plan denied your request. The Plan says preventative vaccines are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under 
Medicare Part B. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to vaccines under 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a TDAP vaccine provided to the 
enrollee on March 5, 2020.  
 
Benefits for vaccines 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of 
intraoral x-rays, and panoramic x-ray provided on January 29, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
panoramic x-ray. You say that you were told that this provider was in-network. You also say that a Plan 
representative set up the appointment with this provider for you. The Plan denied your request. The Plan says 
you self-referred to this OON provider. The Plan also says that services need to be provided in-network to be 
eligible for payment. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray provided on January 
29, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aspirin, Nitroglycerin, Clopidogrel, Lisinopril, 
Levothyroxine, Gabapentin, and Tamsulosin provided on April 28, 2020. 
 
You asked the Plan to pay for the aspirin, Nitroglycerin, Clopidogrel, Lisinopril, Levothyroxine, Gabapentin, 
and Tamsulosin. You say that if the hospital had done the billing right, these self-administered drugs would be 
covered. The Plan denied your request. The Plan says these drugs are self-administered, and are not Part B 
covered. 
 
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 the aspirin, Nitroglycerin, 
Clopidogrel, Lisinopril, Levothyroxine, Gabapentin, and Tamsulosin provided on April 28, 2020.  
 
Benefits for the aspirin, Nitroglycerin, Clopidogrel, Lisinopril, Levothyroxine, Gabapentin, and Tamsulosin 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inherited cancer screening provided to the enrollee on 
February 10, 2020. 
 
You asked the Plan to pay for the screening. You say that the enrollee was not informed of where the analysis 
would be sent to, and therefore can't be held responsible for the charges. The Plan denied your request. The 
Plan says in the absence of current diagnosis or a personal history of a cancer associated with the BRCA 
mutation, coverage guidelines are not met. 
 
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 screening. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the physician's requisition noted a history of stomach cancer in a grandparent, but the billed diagnosis 
was malignant neoplasm of prostate. er the coverage criteria, screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare 
benefit and are not covered. The review has determined that the services at issue in this case were not 
medically reasonable or 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 screening have not been met. Therefore, we decided that the Plan does not 
have to pay for inherited cancer screening provided to the enrollee on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) rendered by the out of network (OON) provider on April 9, 
2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient 
(99334) rendered by the out of network (OON) provider on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 1, 2019. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on 
August 1, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an ear procedure (69779) provided on March 5, 2020. 
 
You asked the Plan to pay for the ear procedure. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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 69799 is unlisted procedure, middle ear  
 
We asked our coder 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 ear procedure. Our reviewer says that CPT code 69799 
meets criteria for billing and reimbursement consideration. Our reviewer found the operative report documents 
for CPT 69799, "first the 0-degree endoscope was used to examine both nasal cavities.  Next, the Entellus 
balloon was inserted through the left nasal cavity into the Eustachian tube orifice.  The balloon was deployed 
for 2 minutes then deflated and removed."  The same was repeated on the right side.  There is no other code 
that exists for Eustachian tube balloon dilation; therefore, documentation supports the use of this CPT code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ear procedure have been met. Therefore, we decided that the Plan has to pay 
for an ear procedure (69779) provided on March 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 20, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
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 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies coded 95909 and the needle 
electromyography services coded 95885 provided on June 13, 2019. 
 
You asked the Plan to pay for the nerve conduction studies and the needle electromyography 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. 
 
We find that CPT codes 95909 and 95885 are not supported in the medical record. Specifically, the technical 
report did not include documentation of nerve conduction studies; for 5-6 studies. Also, the technical report did 
not include documentation of a limited needle electromyography, per each extremity with related paraspinal 
areas when performed, done with nerve conduction, amplitude and latency/velocity study. Based on this 
information, we decided that Medicare rules for coverage of the nerve conduction studies and the needle 
electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the 
nerve conduction studies coded 95909 and the needle electromyography services coded 95885 provided on 
June 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation 
(97112), and gait training therapy (97116) rendered by the out of network (OON) provider from December 3, 
2019 to December 26, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the therapeutic exercises (97110), neuromuscular reeducation (97112), and gait 
training therapy (97116) rendered by the out of network (OON) provider from December 3, 2019 to  
December 26, 2019.