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

 
We decided that the Plan does not have to waive the copayment the specialist visit provided on April 27, 2020. 
 
You asked the Plan to waive the copayment the specialist visit. You say that the doctor called and you spoke 
for about 10 minutes. You say you thought this was a courtesy call and should not be charged. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 Medicare covered specialist visits. 
 
You have been asked to pay a $25 copayment for the specialist visit. The specialist visit falls within the 
?Physician/Practitioner services, including doctor?s office visits? benefit category. The medical record shows 
you were seen for a telemedicine visit and that you were informed this was a billable service. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment a specialist visit provided on April 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage per statute mile (A0425) and transplant 
related lodge, meals & transport per diem (S9975) provided from November 13, 2019 through December 27, 
2019. 
 
You asked the Plan to pay for the services. You say that the receipts represent your post lung transplant doctor 
visit. The Plan denied your request. The Plan says they have limited travel and lodging benefits and these 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Review of the file shows that you had your lung transplant on 
September 24 through October 5, 2018. Per your nurse case manager; ?you can be reimbursed all the way up to 
one year after their transplant date. You had his transplant on September 24, 2019; therefore, you can be 
reimbursed through September 24, 2019. However, you cannot be reimbursed beyond the transplant timeline?. 
Therefore, we decided that the Plan does not have to pay for ground mileage per statute mile (A0425) and 
transplant related lodge, meals & transport per diem (S9975) provided from November 13, 2019 through 
December 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and an X-ray provided on 
May 22, 2020. 
 
You asked the Plan to waive the copayments for a specialist visit and an X-ray. You say that you will pay for 
the first set of X-rays but not the second. 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 $40 
copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $45 
copayment for each basic imaging service. 
 
You had a specialist visit on May 22, 2020. Therefore, you are responsible to pay the $40 copayment.  
 
You received an X-ray on May 22, 2020. Therefore, you are responsible to pay the allowed amount of $32.17, 
which is less than the $45 copayment.  
 
The total amount you owe is: $72.17.   
 
You have been asked to pay the total amount of $72.17 for a specialist visit and an X-ray. A specialist visit falls 
within the physician/practitioner services, including doctor?s office visits benefit category. An X-ray 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 copayments for a specialist visit and an X-ray provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for press-on lens, fresnell prism, per lens (V2718) provided on
April 10, 2020.
You asked the Plan to pay for press-on lens. You say that you are diabetic and is making you see double. You
state you are trying The Plan denied your request. The Plan says this item is not covered under Medicare or the
Health Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of press-on lens have not been met. Review of the file show that you received press-on lens, fresnell
prism, per lens (V2718) provided on April 10, 2020. Your EOC states, "vision Mandatory Supplemental
Benefit Exclusions include, but not limited to, the following: Prisms." Therefore, this is not covered. Therefore,
we decided that the Plan does not have to pay for press-on lens, fresnell prism, per lens (V2718) provided on
April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 23, 2019, October 
12, 2019 and December 6, 2019 by a non-participating provider. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the rules say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
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 the dental services have not been met. In order for the Plan to 
inventory and process the services the Plan requires an itemized statement from the provider that includes each 
date of service, each procedure rendered and what charge correspondence to each individual procedure. The 
Plan states without this information the Plan cannot process your request. The Plan states once you obtain the 
needed information the provider please submit the information to the claims department for processing. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on January 23, 2019, 
October 12, 2019 and December 6, 2019 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on February 24, 2020.
You asked the Plan to pay for the chest x-ray. 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 separately payable.
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, we have confirmed that code 71045 for the chest x-ray has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray coded 71045 provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 3, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (S9328) provided to the enrollee from November 14, 2019 to December 12, 
2019. 
 
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied 
your request. The Plan says that this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered 
as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan 
does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  
 
You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan 
does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay 
for the home infusion therapy, implanted pump pain management infusion; administrative services, 
professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided 
to the enrollee from November 14, 2019 to December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 4, 2019. 
 
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 
physician?s 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 October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture provided on January 31, 
2020. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you were not informed that your 
2020 benefits changed to a preventive plan until February 25, 2020. You also say that the bill for this denture 
was unexpected. The Plan denied your request. The Plan says this prosthetic dental service is not included in 
your benefit plan, and is not 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. In your Annual Notice of Changes for 2020, which was sent to you in 
the Fall of 2019, it states that you would have been responsible a 20% coinsurance for this service if it was 
provided in 2019. This benefit has been removed from you 2020 dental plan, and is no longer covered. 
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture provided on 
January 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS non-emergency ambulance (A0428) and ground
mileage (A0425) provided December 26, 2019.
You asked the Plan to pay for the ambulance services. You say that this was a medically necessary transport.
Your mother is not able to walk home and there was no other form of transport so the hospital requested the
ambulance return. The Plan denied your request. The Plan says the records provided does not support medical
necessity of the ambulance transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation suggests that the other means of transportation including a
wheelchair van was not contraindicated. The documentation does not support that the enrollee required medical
staff and specialized equipment only found in an ambulance. The provided documentation does not support that
the ambulance transport was medically necessary for this enrollee.
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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided
December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 13, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says they were unable to discover any evidence of an established 
relationship between the member and the ordering physician. The Plan states there were no claims submitted 
for an evaluation and management service. The Plan states the review of claims history for this member, and a 
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service 
with the ordering physician as required per CMS guidelines. 
 
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 lumbar-sacral orthosis 
(L0650) provided to the enrollee on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for portable oxygen concentrator (E1392) purchased on 
December 2, 2019 from a non-contracted provider. 
 
You asked the Plan to reimburse for the portable oxygen concentrator. You say that you are requesting 
reimbursement of services rendered. The Plan denied your request. The Plan says the purchased of this item is 
not covered under Medicare or the Health Plan. 
 
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 the portable oxygen concentrator have not been met. Review of the 
file show that you purchased a portable oxygen concentrator (E1392) on December 2, 2019. The Medicare 
rules state, "only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily 
non-covered." Therefore, we decided that the Plan does not have to reimburse for portable oxygen concentrator 
(E1392) purchased on December 2, 2019 from a non-contracted provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection, Nivolumab, 1 mg (J9299) and injection, 
Ipilimumab, 1 mg (J9228), for the enrollee. 
 
You asked the Plan to pre-approve the Medicare Part B Drugs. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Medicare Part B Drugs. Our 
physician reviewer found as patient has failed keytruda, an opdivo containing regimen is not medically 
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 Medicare Part B Drugs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve injection, Nivolumab, 1 mg (J9299) and injection, Ipilimumab, 1 mg 
(J9228), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 9, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 
physician?s 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 December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 10, 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 services rendered by non-participating providers require prior authorization as outlined in the Evidence of Coverage.
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 rendering 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 laboratory services provided to the enrollee on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory work provided by on 
January 22, 2020 and January 29. 2020. 
 
You asked the Plan to waive the copayments for the laboratory work. You say that you are appealing the 
copayments because the provider is charging for blood work and travel allowance. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $50 
copayment for Medicare-covered laboratory services.  
 
You have been asked to pay a total of $58.80 for the laboratory work. The laboratory work 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 copayments for the laboratory work provided by on January 22, 2020 and 
January 29. 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment (D9110) provided on April 6, 2020. 
 
You asked the Plan to pay for palliative treatment (D9110). You say that you needed an extraction, but the 
provider was not qualified to pull your tooth. You say that you shouldn't have to pay the dentist. The Plan 
denied your request. The Plan says the copayment applied correctly. 
 
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 Plan also has a $53 copayment for 
palliative treatment (D9110).  
 
Service Standard Copayment Allowed Amount Member Liability 
Palliative Treatment $53 $49 $49 
 
Therefore, we decided that the Plan does not have to pay for palliative treatment (D9110) provided on April 6, 
2020.