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

 
We decided that the Plan does not have to pay for emergency room services (99285, 93010) provided October 
21, 2019. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency room services was not filed until November 16, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99285, 93010) 
provided October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.

You asked the Plan to pay for incontinence supplies. You say that these supplies should be covered by the Plan. The Plan denied your request. The Plan says incontinence supplies are not covered by the Plan or by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $270 copayment charged for ambulance transport.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. Your
appeal states your claim was denied. The Plan says your claim was not denied. The Plan stated the cost of this
transport was $701. The Plan paid $431 to the provider, leaving your contractual copayment of $270.

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 $270
copayment for ambulance transport. The Plan paid its portion of this claim. 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 $270
copayment charged for ambulance transport.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology services provided 
on September 14, 2020. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging. You say that other plans 
charge less of a copay for this service. The Plan denied your request. The Plan says you were charged the 
copayment 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 $265 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $265 copayment for the magnetic resonance imaging. The magnetic resonance 
imaging falls within the Outpatient Diagnostic Tests 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 diagnostic radiology services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider will not be covered. The provider you requested is not part of your primary care physician's 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on December 21, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you should not be charged for a flu shot. 
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 $15 
copayment for outpatient diagnostic tests/in-network/labs.  
 
You have been asked to pay $2.25 which is less than your copayment of $15 for lab work. Since lab work was 
provided, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/in-
network/labs 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 lab work provided by a 
participating provider on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression System. 
 
You asked the Plan to pre-approve Vertiflex Superion Indirect Decompression System. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
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 Vertiflex Superion Indirect 
Decompression System. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have chronic low back pain. The 
Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. Open 
laminectomy is the gold standard for lumbar decompression. Therefore, you do not meet criteria for the 
requested 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 Vertiflex Superion Indirect Decompression System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression 
System.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to 
dialysis provided on May 25, 2020. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or 
recliner therefore alternatives to transport may include a wheelchair van or a private vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee 
could have been safely transported by another type of vehicle. You did not request prior authorization. Based 
on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport 
have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance 
transport from residence to dialysis provided on May 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided 
on August 18, 2020. 
 
You asked the Plan to waive the copay for the CT scan. You say that had the CT scan been done correctly, you 
might not have needed a colonoscopy. The Plan denied your request.  
 
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 $200 
copay for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $200 copay for the CT scan. The CT scan falls within the outpatient diagnostic 
tests 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 copay for the computed tomography (CT) scan 
provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided from 
October 20, 2020, to October 27, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the services 
billed. The Plan denied your request. The Plan says it is not appropriate to use code 99358 when it is not related 
to a face-to-face service. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical 
record. Specifically, the records do not show that the services were provided in conjunction with direction 
patient care. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services provided from October 20, 2020, to October 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve domiciliary or rest home visits to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve the domiciliary or rest home visits. You say that the home care visits are 
medically necessary. The Plan denied your request. The Plan says it is not medically necessary for the enrollee 
to be seen by an OON 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 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 
domiciliary or rest home visits to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) services rendered on 
May 1, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that codes with a status indicator of X are statutorily excluded from Medicare 
payment and codes with a status indicator of I are not valid for Medicare purposes. 
 
The insert/clamp device at issue is not covered because it does not serve a purpose that is primarily medical in 
nature. The DME set-up services billed with code A9901 are not covered because this code has a status 
indicator of X and is not payable by Medicare. The sales tax billed with code S9999 is not covered because it 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment (DME) services rendered on May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 
17, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel that this service should 
be covered because you did not choose to change dentists. The Plan denied your request. The Plan says benefits 
for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, comprehensive oral evaluation and is 
limited to one procedure every three years. The record shows that you received a comprehensive oral 
evaluation on April 23, 2019 and your comprehensive oral evaluation benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services and 
coinsurance for an injection provided by a participating provider on September 29, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services and coinsurance for an injection. 
You say that this cost-sharing amount is way too high. The Plan denied your request. The Plan says the correct 
cost-sharing amounts have 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 $275 
copayment for outpatient hospital services and a 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $60.76 which is less than your copayment amount of $275 copayment for 
outpatient hospital services and a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount for the injection is $1,194.06. The amount you are being asked to pay for an injection is $238.81 
($1,194.06 x 20% = $238.81). The total amount you are being asked to pay is $299.57 ($238.81 + $60.76 = 
$299.57). Outpatient hospital services falls within the outpatient hospital services benefit category and an 
injection falls within the Medicare Part B prescription drugs 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 outpatient hospital services and coinsurance for an injection provided by a 
participating provider on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and four 
additional intraoral periapical x-rays (D0230 x4) provided on December 2, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that these services should be covered. 
The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency 
limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received five additional intraoral periapical x-rays on 
December 2, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit had been 
exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray 
(D0220) and four additional intraoral periapical x-rays (D0230 x4) provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression stockings. 
 
You asked the Plan to pre-approve the compression stockings. You say that this item is medically necessary. 
The Plan denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve the compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies (S1015, S8301) provided on September 25, 2020. 
 
You asked the Plan to pay for supplies. You say that these are the codes for the items that the provider brought. 
The Plan denied your request. The Plan says these codes are not valid. 
 
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 S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for supplies (S1015, S8301) provided on September 
25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
periapical first radiographic image (D0220), unspecified preventative procedure (D1999) provided November 
5, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, periapical x-ray and unspecified preventative 
procedure. You say that you should not have to pay for the x-ray since you did not receive subsequent services 
from the provider. The Plan denied your request. The Plan says the services are not covered. 
 
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 
limited oral evaluation - problem focused (D0140), periapical first radiographic image (D0220), unspecified 
preventative procedure (D1999) provided November 5, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a PET scan provided to the enrollee on September 10, 2020. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says that claims must be billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the services 
at issue in this case were medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the provision of the PET scan was medically necessary and reasonable. The enrollee 
appears to have metastatic colon cancer, which is a reasonable diagnosis. The PET imaging appears to have 
been completed to follow up on progression of disease. 
 
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 scan have been met. Therefore, we decided that the Plan has to pay for a 
PET scan provided to the enrollee on September 10, 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 pre-approve one additional pontic (D6242) and one retainer crown 
(D6752). 
 
You asked the Plan to pre-approve the additional pontic and retainer crown. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says you have reached the maximum cap on your 
coverage. 
 
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 offers a $5,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on March 12, 2021 when the 7 
pontics and 4 retainer crowns were approved for coverage, totaling $5,021.50 for the approved services, and 
your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve one additional pontic (D6242) and one retainer crown (D6752).