Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that that there is a lack of documentation of failure of BiPap. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that a portable ventilator is medically reasonable and necessary for the enrollee in this case. You clearly 
document that a Bipap would be inadequate. The severity of the COPD and restrictive lung disease is 
confirmed by the documentation provided. Our physician reviewer found that the enrollee's condition meets 
Medicare criteria for a portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan has 
to pre-approve a portable ventilator for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
18, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were told that you would not owe a copayment and feel that the clinic where you fell should be 
responsible. 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 a $25 
copayment for ambulance services.  
 
You have been asked to pay a $25 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on June 25, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were admitted to the 
hospital so these services were emergent. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for an ambulance trip. An ambulance copayment is not waived 
if admitted to the hospital. An ambulance trip falls within the ambulance services 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 an ambulance trip provided by a participating provider on June 25, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7140), the sinus augmentation 
(D7951), and the bone replacement graft for ridge preservation (D7953) provided on July 28, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that the services were medically 
necessary. You also say that you should be reimbursed for the services. The Plan denied your request. The Plan 
says extractions are not listed as a covered service. The Plan says sinus augmentation is not listed as a covered 
service. The Plan says bone graft for ridge preservation is not listed as a covered service either. 
 
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 reimburse you for 
the extraction (D7140), the sinus augmentation (D7951), and the bone replacement graft for ridge preservation 
(D7953) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) and 2 retainer crowns (D6740) provided 
on January 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised that your dental coverage 
would be effective on February 1, 2020. You say that you have been advised that the claim should be paid but 
that it keeps coming back denied. You say that you paid for $1,501.50 of the bill on a credit card with the 
expectation that it would be reimbursed. You also say that you cannot afford to pay the remaining portion of 
this bill. The Plan denied your request. The Plan says the pontic is not listed as a covered service. The Plan says 
that retainer crowns are not listed as covered services either. 
 
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 dental services you received are not 
among those covered under this benefit. The record shows that your enrollment in the optional supplemental 
dental benefit was not effective until February 1, 2020. Additionally, you were not enrolled in the optional 
supplemental dental benefit on the date of service. Therefore, we decided that the Plan does not have to pay for 
the pontic (D6245) and 2 retainer crowns (D6740) provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Dexcom G6 therapeutic continuous glucose monitor 
(CGM) and supplies (K0553, K0554). 
 
You asked the Plan to preapprove the CGM. You say that the enrollee requires a new CGM The Plan denied 
your request. The Plan says there is no documentation explaining why the enrollee requires a replacement.  
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. Replacement of the continuous glucose monitor due to slight damage to 
the device without causing the device to malfunction or replacement desired due to advanced technology is 
considered not medically necessary. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a 
reasonable reason for needing a new CGM. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a 
Dexcom G6 therapeutic continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urine capacity measurement and 
laboratory tests provided on August 18, 2020, and August 26, 2020. 
 
You asked the Plan to waive the copayment for the urine capacity measurement and laboratory tests. You say 
that you shouldn't have to pay any copayments associated with the surgery. The Plan denied your request. The 
Plan says 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). Your contract with the Plan clearly says that you must pay a $20 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds. 
 
You have been asked to pay a total of $30.55 for the urine capacity measurement and laboratory tests.  
 
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
August 18, 2020 Urine Capacity 
Measurement 
$11.10 $20 $11.10 
August 26, 2020 Urine Capacity 
Measurement & 
Laboratory Tests 
$19.45 $20 $19.45 
TOTAL:    $30.55 
 
  
 
 
The urine capacity measurement and laboratory tests fall 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 the urine 
capacity measurement and laboratory tests provided on August 18, 2020, and August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
6, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were unaware the code 
being billed was not covered as it was covered last year. The Plan denied your request. The Plan says the dental 
service that was denied is not covered by your health plan or Medicare. 
 
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 
comprehensive oral evaluation (D0150) provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs and medicaments (D9630) provided on August 6, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied 
your request. The Plan says drugs and medicament is not listed as a covered service. 
 
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 drugs 
and medicaments (D9630) provided on August 6, 2020.  
 
There is not enrollee liability for the unspecified preventive service (D1999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided from August 30, 2019, to 
December 17, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
Medicare rules also say that rocedures should be reported with the CPT code that describes the services 
performed. 
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records do not indicate that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Additionally, the records do not support the 
use of CPT codes P9604 and P9603 for the dates of service in question. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided from August 30, 2019, to December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (E1399), a CPAP battery 
backup. 
 
You asked the Plan to pre-approve the backup battery for CPAP. You say that the enrollee requires the device 
because of frequent outages. The Plan denied your request. The Plan says the service is not covered under 
original Medicare so it is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be a covered 
item. The item at issue in this appeal is not a covered item. Therefore, we decided that the Plan does not have to 
pre-approve durable medical equipment (E1399), a CPAP battery backup.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs 
which would meet the guidelines for continued SNF services on a daily basis. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision care provided on July 21, 2020. 
 
You asked the Plan to waive the deductible for vision care. You say that you disagree with the charges because 
the provider is in-network and you received medical services not routine. 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 $1,500 deductible for out-of-network vision care.  
 
You received vision care on July 21, 2020, from an out-of-network provider. The record shows that you had 
paid $0 toward the $1,500 deductible prior to receiving the services. Therefore, you are responsible to pay the 
allowed amount of $104.80.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for 
vision care. This cost sharing is a contractual obligation that had not been met at the time vision care was 
received on July 21, 2020. Therefore, we decided that the Plan does not have to waive the deductible for vision 
care provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased July 7, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like to be reimbursed for the hearing 
aids you purchased. The Plan denied your request. The Plan says you must obtain the services from the Plan's 
hearing aid vendor in order to be eligible for coverage. 
 
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 when purchased from the Plan?s hearing aid vendor.  
 
We looked at the file and the Plan's rules. The information in the case file indicates that the hearing aids were 
not purchased from the Plans hearing aid vendor. 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 pay 
for the hearing aids purchased July 7, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on December 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the provider did 
not perform this service. 
 
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. The Plan says that the billing provider did not perform the service in question. 
However, the records provided do show that the billing provider was the provider of the drug testing services. 
The Plan has not provided documentation to substantiate its denial. Therefore, we decided that the Plan has to 
pay for the drug testing services provided on December 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Corus CAD test (81493) provided on May 29, 2020. 
 
You asked the Plan to pay for a Corus CAD test. You say that these services were required to treat the patient 
safely. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for the Corus 
CAD test. 
 
We looked at the file and Medicare rules. The test at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of a Corus CAD test have not been met. Therefore, we decided that 
the Plan does not have to pay for a Corus CAD test (81493) provided on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs may be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lower extremity 
cellulitis and congestive heart failure. The enrollee's medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) 
provided on June 1, 2020. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says a secondary only 
diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99442 is not supported in the record. Specifically, this claim was billed with diagnosis 
code F01.51 as the first listed, primary diagnosis. Per the ICD-10, diagnosis code F01.51 has a code first note 
indicating that it should be listed after the diagnosis code for the underlying condition. Based on this 
information, we decided that Medicare rules for coverage of the telephone evaluation and management service 
have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and 
management service (99442) provided on June 1, 2020.