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

We decided that the Plan does not have to pay for the services (CPT 81003) provided on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 81003 is "Urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 81003 is not supported by the records provided. Our coding reviewer found that the office visit 
did not include documentation that a Urinalysis by dip stick or tablet was performed. Services performed while 
in the office should clearly document the service provided, as well as, the results, to verify services were 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 81003) provided on June 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone mass measurement (BMM) scan rendered on 
November 18, 2019. 
 
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 exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that a BMM scan is covered once every two years. 
 
We looked at the file and Medicare rules. The file shows that you previously had a bone density scan on 
September 26, 2018 that the Plan covered. The BMM on November 18, 2019 was performed less than 24 
months from your previously covered BMM. Therefore, we decided that the Plan does not have to pay for the 
bone mass measurement (BMM) scan rendered on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the exercise equipment (A9300) purchased on 
July 24, 2020. 
 
You asked the Plan to reimburse you for the exercise equipment. You say that you would like to be reimbursed 
for this exercise equipment. The Plan denied your request. The Plan says you did not purchase the equipment 
between October 1, 2020, and December 31, 2020. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers exercise 
equipment in lieu of gym membership services for exercise equipment purchased between October 1, 2020, to 
December 31, 2020. 
 
The Plan?s rules for coverage of exercise equipment have not been met because they were purchased prior to 
October 1, 2020. Therefore, we decided that the Plan does not have to reimburse you for the exercise 
equipment (A9300) purchased on July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound rendered on November 23, 2020. 
 
You asked the Plan to pay for these services. You say that the services were previously fully covered. The Plan 
denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ultrasound services.  
 
Review of the file shows that you received an ultrasound on November 23, 2020. You have been asked to pay a 
$100 copayment for these services. These services fall within the ultrasound 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 pay for the ultrasound rendered on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from February 7, 2020 to February 28, 
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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for the services rendered from February 7, 2020 to 
February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for pulmonary diagnostic testing and therapies provided on June 
4, 2020. 
 
You asked the Plan to pay for the pulmonary diagnostic testing and therapies. 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for pulmonary diagnostic testing and therapies provided on June 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 5, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services rendered from February 12, 
2020, to June 29, 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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a Licensed Professional Counselor (LPC) is not 
eligible to participate in Medicare.  
 
We looked at the file and Medicare rules. The services were rendered by a Licensed Professional Counselor. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the behavioral health services rendered from 
February 12, 2020, to June 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 1, 2020. 
 
You asked the Plan to pay for the psychotherapy 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 
psychotherapy 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 psychotherapy services provided on September 1, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on 
December 3, 2019. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were told cost-sharing was 
being waived for all telehealth visits. The Plan denied your request. The Plan says the cost-sharing waiver was 
not in effect when you received this service. 
 
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 each visit or consultation with a specialist.  
 
You have been asked to pay a $40 copayment for an office visit. 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 office visit (99213) provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two fillings, prophylaxis, the periodic oral exam, and the 
unspecified adjunctive procedure provided on August 12, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were never informed that the provider 
needed to participate in the Medicare program. You say that the Annual Notice of Changes for 2020 does not 
reflect that you need to use and in network provider for non-Medicare covered dental services. You also say 
that you received dental services from the same dentist in 2019 and was reimbursed. The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment 
cannot be made for services that you receive from a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the two 
fillings, prophylaxis, the periodic oral exam, and the unspecified adjunctive procedure provided on August 12, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray (73030) and ultrasound (76882) 
provided on October 21, 2020 and October 23, 2020. 
 
You asked the Plan to waive the copayments for the x-ray and ultrasound. You say that you should not be held 
responsible for the imaging services because you were not responsible for the damage done to your arm, and 
that this damage is what made these services necessary. The Plan denied your request. The Plan says an x-ray 
and an ultrasound were provided, and each of these services have a $30 copayment. 
 
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 $30 
copayment for basic imaging services within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category.  
 
You have been asked to pay a $30 copayment for an x-ray and a $30 copayment for an ultrasound. Both 
services are considered basic imaging services 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 x-ray (73030) and 
ultrasound (76882) provided on October 21, 2020 and October 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided from February 6, 2020, through 
October 1, 2020. 
 
You asked the Plan to pay for the speech therapy. The Plan denied your request. The Plan says the enrollee 
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 
speech therapy. 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 speech therapy provided from February 6, 2020, through October 
1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Freestyle Libre Sensor Continuous Glucose monitor 
(CGM). 
 
You asked the Plan to preapprove the CGM. You say that the enrollee requires the device. The Plan denied 
your request. The Plan says you do not meet Medicare coverage criteria because you are not on insulin. 
 
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. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. 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 Freestyle Libre Sensor 
Continuous Glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the personal protective equipment (D1999) 
provided from August 31, 2020, to September 28, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that the $15 PPE charges were not 
voluntary. You say that they were mandatory to see the dentist. You say that you needed to see the dentist due 
to pain that you were experiencing in the lower right side of your mouth. The Plan denied your request. The 
Plan says personal protective equipment 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 reimburse you for 
the personal protective equipment (D1999) provided from August 31, 2020, to September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required provided 
on September 30, 2020. 
 
You asked the Plan to pay for the core buildup. You say that you do not see where this service is excluded from 
coverage. You also say that the buildup is necessary to support the crown that was installed. The Plan denied 
your request. The Plan says this service is 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 core 
buildup, including any pins when required provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided from July 16, 2020, through July 30, 
2020. 
 
You asked the Plan to pay for the injections. 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for injections provided from July 16, 2020, through July 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Pulmonary Diagnostic Testing and 
Therapies provided on June 23, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic testing. You say that since you were referred to 
the specialist the entirety of the claim should have been covered for the visit. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received Pulmonary Diagnostic Testing and Therapies on June 23, 2020. You 
were asked to pay a $50 copayment for the services. Your 2020 EOC states that enrollees must pay a $0 to $50 
copayment for Medicare-covered diagnostic procedures and tests. 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 Pulmonary Diagnostic Testing and Therapies provided on June 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) provided from May 26, 
2020, to June 24, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the services that the enrollee received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no 
nursing services which would be considered skilled services by Medicare. 
 
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 pay for the SNF services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse.  
 
The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a SNF setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) provided from May 26, 2020, to June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires, (e.g., apnea monitor), per pair (CPT Code A4557) 
provided to the enrollee on September 18, 2020. 
 
You asked the Plan to pay for the lead wires. You say that per the LCD, A4557 is not inclusive to A4595 and is 
separately reimbursable. The Plan denied your request. The Plan says replacement of lead wires (A4557) more 
often than every 12 months would rarely be reasonable and necessary. 
 
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 lead wires have not been met.  A transcutaneous electrical 
nerve stimulation (TENS) unit has been purchased in the previous 12 months for TENS unit (CPT Code 
E0730) billed by the same provider under for date of service December 18, 2019, for date of service January 
18, 2020, and for date of service February 18, 2020. Per CMS LCD L33802, "Replacement of lead wires more 
often than every 12 months would rarely be reasonable and necessary?. Since a TENS unit has been purchased 
in the previous 12 months, the lead wires have been denied. Records supporting the medical necessity of the 
additional lead wires were not submitted. Therefore, recommendation for CPT code A4557 is to uphold the 
original denial. Therefore, we decided that the Plan does not have to pay for lead wires, (e.g., apnea monitor), 
per pair (CPT Code A4557) provided to the enrollee on September 18, 2020.