Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased September 15, 2020, from an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like the allowance applied to this case. 
The Plan denied your request. The Plan says hearing aids are not covered by the Plan. 
 
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 they are purchased from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan?s original denial for this service was based on using an 
incorrect evidence of coverage. The correct evidence of coverage indicates that hearing aids are covered but 
only when they are purchased from an in-network provider. In this case, you purchased hearing aids from an 
OON provider. 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 
September 15, 2020, from an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429-QL) provided March 31, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that cases where the beneficiary was pronounced 
dead after the ambulance is called but before the ambulance arrives at the scene must be coded with A0428. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the 
appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. 
Medicare requires the reporting of A0428 for services provided under these circumstances. 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 the ambulance services (A0429-QL) provided 
March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cast supplies coded A4580 and the impression casting of 
a foot services coded S0395 provided on July 7, 2020. 
 
You asked the Plan to pay for the cast supplies and the impression casting of a foot services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered are not a covered benefit. 
 
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 A4580 and S0395 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the cast supplies and the impression casting of a foot services have 
not been met. Therefore, we decided that the Plan does not have to pay for the cast supplies coded A4580 and 
the impression casting of a foot services coded S0395 provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation and set up of the portable x-ray (Q0092 
and R0070) provided on August 7, 2020. 
 
You asked the Plan to pay for the transportation and set up of the portable x-ray. You say that you would like 
reconsideration because this claim was billed with the correct place of service. The Plan denied your request. 
The Plan says the technical component representing the procedure itself, including any associated 
transportation and setup costs, would be subject to consolidated billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to 
consolidated billing and not separately billable to Medicare Part B. 
 
We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, this claim was 
billed with Place of Service code 31 indicating that the member was in a Part A Skilled Nursing Facility stay. 
This means that the set up and transportation costs are subject to consolidated billing and not separately 
billable. Based on this information, we decided that Medicare rules for coverage of the transportation and set 
up of the portable x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
transportation and set up of the portable x-ray (Q0092 and R0070) provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 16, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on September 16, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from September 9, 
2020, to September 11, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that this claim was bundled and routed to 
the medical claims department instead of the pharmacy prescription claims department. The Plan denied your 
request. The Plan says the drugs received are self-administered drugs, and are not covered under Part B. 
 
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 self-administered drugs 
provided from September 9, 2020, to September 11, 2020.  
 
Benefits for the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility beyond 
February 13, 2021 for the enrollee. 
 
You asked the Plan to pre-approve the continued services. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical conditions have improved, and the enrollee is no longer a treat to 
themselves or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued services. Our reviewer 
says that the requested continued services are not medically reasonable or necessary. Our physician reviewer 
found the health plan's denial of continued inpatient psychiatric services is appropriate. The enrollee does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 12, 
2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any 
auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing 
any aggressive behaviors or any treatment required for acute threats of safety. 
 
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 continued services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to an inpatient mental health facility beyond February 13, 2021 for the 
enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the long term care services in a skilled nursing facility (SNF) 
provided from November 22, 2019, to December 21, 2019. 
 
You asked the Plan to pay for the long term care services. You say that that the services that were provided to 
the enrollee are coverable under the Medicare Act. The Plan denied your request. The Plan says that long term 
care in a skilled nursing facility is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the long term care services in a skilled nursing facility (SNF) provided from November 22, 2019, to 
December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for two injections of Pegfilgrastim (J2505) 
provided between January 2, 2020 and January 31, 2020. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that the Plan did not cover this 
drug. The Plan denied your request. The Plan says the drug in question is covered, but Medicare Part B drugs 
have a 20% coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for drug injections. Drug injections fall within the Medicare Part 
B drugs benefit category. The Plan's allowed amount for each Pegfilgrastim injection is $4,342.24 ($4,342.24 x 
20% = $868.45 per injection, or $1,736.90 for both). This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
two injections of Pegfilgrastim (J2505) provided between January 2, 2020 and January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0648) provided on May 7, 2020. 
 
You asked the Plan to pay for the back brace. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not include a valid 
proof of delivery. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted does not link the 
supplier's record to the delivery service record by a clear method such as the package ID or supplier's invoice. 
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 back brace (L0648) provided on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided August 20, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was not billed with the appropriate CPT code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, this service should be billed 
using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) 
provided August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride (D1208), periodontal 
maintenance (D4910), and the unspecified preventive procedure (D1999) provided on September 18, 2020. 
 
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 topical application of fluoride and the 
periodontal maintenance are not a covered benefit under your dental policy. Additional payment cannot be 
issued for the unspecified preventive procedure as participating providers receive a monthly stipend for this 
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 topical application of fluoride and 
periodontal maintenance provided are not among those services covered under this benefit. An additional 
payment cannot be issued for the unspecified preventive procedure as participating providers receive a monthly 
stipend for this service. Therefore, we decided that the Plan does not have to issue reimbursement for the 
topical application of fluoride (D1208), periodontal maintenance (D4910), and the unspecified preventive 
procedure (D1999) provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the RT300 functional neuromuscular electrical 
stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this device will not improve the level of function in any way. 
 
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 the stimulator. Our reviewer says that 
the requested stimulator is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the requested functional neuromuscular electrical 
stimulator is medically reasonable and necessary for the enrollee in this case. It has not been demonstrated that 
the enrollee is likely to benefit to a significant extent from the requested DME. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the RT300 functional neuromuscular electrical stimulator for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for a Tempus xF Gene Panel (81298, 81317, 81292). 
 
You asked the Plan to pay for a Tempus xF Gene Panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says that this test is not FDA approved and has not had a technology assessment. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a diagnostic 
laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory 
Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when the 
above requirements are met. 
 
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 a Tempus xF Gene Panel. Our reviewer says 
that the criteria for coverage of the tests at issue have been met. Our physician reviewer found Molecular 
Diagnostic Studies in Non-Small Cell Lung Cancer (NSCLC) are considered a standard of care. Numerous 
gene alterations have been identified that impact therapy selection. The NCCN NSCLC Guidelines Panel 
strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which 
effective drugs may already be available, or to appropriately counsel patients regarding the availability of 
clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with 
NSCLC.  Testing of lung cancer specimens for these alterations is important for identification of potentially 
efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. This patient 
has stage IV NSCLC and no prior molecular profiling. Molecular profiling such as with Tempus is reasonable 
and 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 a Tempus xF Gene Panel have been met. Therefore, we decided that the Plan 
has to pay for a Tempus xF Gene Panel (81298, 81317, 81292).  
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on July 8, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the psychiatric services. You say that the provider is in network. The Plan denied 
your request. The Plan says prior authorization was required but not requested. 
 
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 had network providers 
available who could have provided the services 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 these services. Therefore, we decided 
that the Plan does not have to pay for the psychiatric services provided on July 8, 2020 by an out of network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) and arterial studies (93925, 93922) 
provided on March 19, 2019. 
 
You asked the Plan to pay for an office visit and arterial studies. You say that this claim was filed timely. The 
Plan denied your request. The Plan says this claim is a duplicate of a previous claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The record shows that the claim at issue is an exact duplicate of a 
previous claim that applied to the enrollee's deductible. Based on this information, we decided that Medicare 
rules for coverage of an office visit and arterial studies have not been met. Therefore, we decided that the Plan 
does not have to pay for an office visit (99204) and arterial studies (93925, 93922) provided on March 19, 
2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the one month supply of continuous glucose monitor supplies (K0553) 
provided on March 26, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies. You say that you would like 
reconsideration because these services are authorized by the Plan. The Plan denied your request. The Plan says 
that this service is only allowed once per month. 
 
The Plan must follow Medicare rules. Medicare rules say that for delivery of refills, the supplier must deliver 
the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor supplies have been met. Specifically, the record indicates that this 
service was billed on March 3, 2020 and then again on March 26, 2020. This is within the 10 day allowable 
time frame for the delivery of refills. Therefore, we decided that the Plan has to pay for the one month supply 
of continuous glucose monitor supplies (K0553) provided on March 26, 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.