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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, E1007, E1028, K0108, E0955) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the wheelchair is approved except for the denied codes. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically 
necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The 
documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-
proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices 
(e.g., sip and puff, head array, etc.)  
 
 
 
 
The patient does not need to operate 3 or more powered seating actuators through the drive control, a  separate 
display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech 
device or computer through the chair's drive control), or an attendant control. The enrollee's strength and 
functional ability should be sufficient to control any power options through their own switches. The 
documentation indicates the enrollee performs self-catheterization and is able to transfer independently. There 
is no evidence of need for increased tone or spasticity or a high risk of developing pressure ulcers. The criteria 
for an E1007 has not been met. Per the criteria, if the enrollee has a POV or a power wheelchair with a 
captain's chair seat, a headrest or other positioning accessory will be denied as not reasonable and necessary. 
The enrollee's wheelchair has a captain's chair seat therefore the E0955 and E1028 headreast hardware are not 
appropriate or medically necessary. The additional K0108 items do not serve a primary medical need and are 
therefore 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, E1007, E1028, K0108, 
E0955) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport provided May 28, 2019. 
 
You asked the Plan to pay for the air ambulance transport. You say that the air ambulance service was 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the air ambulance 
was not necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our reviewer 
says that the requested service was not medically necessary or reasonable. Our physician reviewer found the 
review has determined that the documentation did support that the patient suffered from an illness or injury that 
contraindicated transportation by any means other than ambulance. However, the documentation does not 
support that the patient's condition was such that the time needed to transport a patient by ground, or the 
instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the 
patient's health. The documentation did not support that the transferring hospital did not have adequate 
facilities to provide the medical services needed by the patient. 
 
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 air ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance transport provided May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 
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 the medical services provided to the enrollee by an out-of-
network provider on September 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 
29, 2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you received a $200 
copayment for something you did not want. You say the ambulance took you to the emergency room to get 
checked out. 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 $200 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance ride provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553) provided 
on May 22, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the medical records that were 
received were dated August 2019 which means the member was not seen for almost a year for diabetes by this 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic continuous glucose monitors and 
related supplies are covered by Medicare when every six (6) months following the initial prescription of the 
continuous glucose monitor, the treating practitioner has an in-person visit with the beneficiary to assess 
adherence to their continuous glucose monitor regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor have not been met. Specifically, there is no documentation to 
support that the member has had an in-person visit with their treating practitioner to assess the adherence to 
their regimen and diabetes treatment plan. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor supplies (K0553) provided on May 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from December 2, 2019, to 
December 19, 2019 by an OON provider. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim to be reprocessed 
for payment. The Plan denied your request. The Plan says the treating provider is not in-network. The Plan also 
says that there is no authorization on file. 
 
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 
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 medical services provided from December 2, 
2019, to December 19, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on August 3, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you want to appeal this service. The 
Plan denied your request. The Plan says this benefit had 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, periodic oral evaluations are limited to 
one every six months. The record shows that you received a periodic oral evaluation on November 6, 2020, and 
your periodic oral evaluation benefit had been exhausted. Therefore, we decided that the Plan does not have to 
pay for the periodic oral evaluation provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure provided on September 22, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you were advised by the Plan that this 
provider was in-network. The Plan denied your request. The Plan says this service is not covered. The Plan also 
says that participating providers are receiving a separate monthly stipend for the unspecified preventive 
procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure provided on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance services provided from April 
21, 2020, to May 2, 2020. 
 
You asked the Plan to waive the copayments for ambulance services. You say that you were not aware that you 
would owe copayments for the services. 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 $250 
copayment for ambulance services.  
 
You received ambulance services from April 21, 2020, to May 2, 2020 for a total of 10 services. Therefore, you 
are responsible to pay the total allowed amount of $2,174.45, which is less than the total copayment amount.  
 
You have been asked to pay the total copayment amount of $2,174.45 for ambulance services. Ambulance 
services fall within the ambulance services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for ambulance services provided from April 21, 2020, to May 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 1, 2019, through August 2, 2019. 
 
You asked the Plan to pay for the SNF services. You say that this was correctly billed according to your 
contract. The Plan denied your request. The Plan says this was not billed correctly for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that SNFs can receive payment for services under 
Part A when a proper PPS claim is submitted. This claim requires at least one line item with revenue code 0022 
to report a HIPPS code. 
 
In this case, only a single line item was billed. This line item was not for revenue code 0022 and no HIPPS 
code was included. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) services provided from August 1, 2019, through August 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis 
rendered on July 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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The 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 file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 computed tomography (CT) scan of the abdomen/pelvis rendered on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on 
September 5, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says the orthoses are not supported in the 
medical records received. 
 
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 knee orthosis (L1833) and suspension 
sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found 
the enrollee's chief complaint was chronic left knee, right knee pain. The documentation in the case file does 
not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the 
enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of 
recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective 
documentation of joint laxity. The documentation in the case file does not support that the requested knee 
orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the 
coverage criteria established by the LCD. There is insufficient documentation of an examination of the 
enrollee, and there is insufficient credible objective documentation of joint laxity. 
 
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 knee orthosis (L1833) and suspension sleeve (L2397) have not been met. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided 
on September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutritional counseling services (97802) provided on May 
12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the nutritional counseling services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. 
 
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 nutritional counseling services (97802) provided on May 12, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, prophylaxis, and 
topical application of fluoride varnish provided on August 21, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, prophylaxis, and topical application of 
fluoride varnish. You say that you would like to be reimbursed for these services. You also say that you have 
seen this provider for 4 years and have been reimbursed for the services. The Plan denied your request. The 
Plan says the treating provider opted out of Medicare effective September 1, 2015, to September 1, 2021. The 
Plan also says that services performed by a privately contracted provider are not covered. 
 
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 
periodic oral evaluation, bitewings, prophylaxis, and topical application of fluoride varnish provided on August 
21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953), nor adjust the cost 
sharing applied to the extraction of an erupted tooth (D7210), a limited oral evaluation (D0140), and intraoral-
periapical first radiographic image (D0220) provided on September 28, 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 a bone replacement graft is not a covered 
benefit under your dental policy. Additionally, the cost sharing has been applied correctly to the tooth 
extraction, limited oral evaluation, and intraoral x-ray provided.  
 
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 bone replacement graft is not 
among those services covered under this benefit. Additionally, the dental extraction was billed in the amount of 
$395, less the $100 deductible applied, which is $295 x 40% coinsurance plus the deductible included; your 
responsibility is $218 with payment from the plan at $177. The limited oral evaluation was billed in the amount 
of $85 x 20% coinsurance in which $68 was paid and the intraoral-periapical x-ray was billed in the amount of 
$35 x 20% coinsurance in which $28 was paid.  
 
 
 
 
 
 
 
 
 
 
 
The plan reimbursed you the correct amount of $273 for these services rendered. Therefore, we decided that the 
Plan does not have to pay for the bone replacement graft (D7953), nor adjust the cost sharing applied to the 
extraction of an erupted tooth (D7210), a limited oral evaluation (D0140), and intraoral-periapical first 
radiographic image (D0220) provided on September 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump and supplies rendered from 
April 15, 2020, to April 22, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that 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. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulatory infusion pump and supplies rendered from April 15, 2020, to April 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 16, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this appointment was preventive 
and not diagnostic. 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 $10 
copayment for Medicare-covered physician services.  
 
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
practitioner services, including doctor's office visits" benefit category. The medical record shows in addition to 
routine preventive health issues, you were also seen for a follow-up on chronic health conditions such as your 
left shoulder and hypercholesterolemia. 
 
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 office visit provided on September 16, 2020.