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

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve the powered pressure-reducing air mattress. You say that the durable
medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules
have not been met.
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 powered pressure-reducing air mattress have not been met. The
medical records do not show that you have pressure ulcers or that you are high risk for them or that you are bed
bound. Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air
mattress (E0277).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for intermittent urinary catheters (A4351) provided on October 25, 2019.
You asked the Plan to pay for the intermittent urinary catheters. You say that you would like reconsideration based on the submitted documentation because the billed supplies are medically necessary. The Plan denied your request. The Plan says that the submitted medical records do not include an itemized delivery ticket for the billed date of service.
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 contains a valid proof of delivery for the supplies provided in this case. The Proof of Delivery included in the additional medical records submitted to the Plan is for the date of service billed and is appropriately signed by the member. Therefore, we decided that the Plan has to pay for intermittent urinary catheters (A4351) provided on October 25, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 14, 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 has network providers
available who can provide 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 you by an out-of-network provider on
January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided to the enrollee on June 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires use of CPT 81479 to report comprehensive genomic profile (CGP) testing for breast cancer.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 comprehensive genomic profile (CGP) testing provided to the enrollee on June 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a nuclear medicine stress test,
echocardiogram, and the ultrasound provided on August 5, 2019 and August 19, 2019.
You asked the Plan to waive the copayments for the nuclear medicine stress test, the echocardiogram, and the
ultrasound. You say that you have to pay two separate copayments because you could not have both services
done on the same day. 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 $135
copayment for each Medicare-covered MRI, PET scan, or Nuclear Medicine visit and a $65 copayment for
other outpatient diagnostic testing.
You have been asked to pay a $135 copayment for the nuclear medicine stress test and a $65 copayment for the
echocardiogram and the ultrasound. The nuclear medicine stress test, the echocardiogram, and the ultrasound
fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record
shows you received these services on different days.
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 nuclear medicine stress test, the echocardiogram, and
the ultrasound provided on August 5, 2019 and August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 25,
2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you have never had to pay a
$200 copayment before. You say you did not receive the injection at the hospital. 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 for Medicare-covered surgery at an outpatient hospital facility.
You have been asked to pay a $200 copayment for the arthrocentesis. The arthrocentesis falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows you were billed by the outpatient hospital.
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 arthrocentesis provided on February 25, 2020.
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-ofnetwork
provider on February 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide 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 February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper and lower denture provided on
December 23, 2019.
You asked the Plan to pay more for the complete upper and lower denture. You say that your policy covers
complete dentures with 25% or 30% coinsurance with no deductible. You say that this should be processed for
payment. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 25%
of the allowed amount for the dentures.
The complete upper and lower denture were received from an out-of-network provider. Therefore, we decided
that the Plan does not have to pay more for the complete upper and lower denture provided on December 23,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 14, 2019.
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 the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT (computed tomography) of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT of the abdomen and pelvis. You say that this is necessary for restaging. The Plan denied your request. The Plan says only a CT of the chest is indicated.
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve a CT of the abdomen and pelvis. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found per NCCN guidelines for non-small cell lung cancer, a CT of the chest is recommended every 6 months for 2 to 3 years. A CT of the abdomen and pelvis is not recommended. 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 CT of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT (computed tomography) of the abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services you received on February 6,
2020.
You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible
for the cost share.
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 20%
coinsurance for Medicare Part B drugs. Your contract also says that you must pay a $390 copayment for
outpatient surgery services.
Review of the file shows that you were provided Part B drugs and outpatient surgery services on February 6,
2020. You have been asked to pay a 20% coinsurance for the Part B drugs. The surgery services were allowed
at $355.55, which is less than the $390 copayment outlines in the Plan contract. You have been asked to pay
the lesser amount for the surgery services. 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 cost share for the services
you received on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the urgent care visits provided from February 2, 2020 to March 3, 2020.
You asked the Plan to reduce the copayments for the urgent care visits. You say that you were charged a $40 copayment for your first visit and then $5 copayments for the following visits. You should only be responsible for the $5 copayments. 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 $40 copayment for each Medicare-covered urgent care facility. You have been asked to pay a $40 copayment for each of the urgent care visits. ($40 x 5 visits = $200). The urgent care visits fall within the "Urgently needed 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 reduce the copayments for the urgent care visits provided from February 2, 2020 to March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are only covered for 20 one-way trips per calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used 16 one-way trips as of July 3, 2020. Your contract clearly says that you are allowed 20 one-way trips per calendar year. You have 4 remaining one-way trips as of July 3, 2020 and once these 4 trips are used you will have exhausted this benefit for the 2020 calendar year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nexletol Tablet.
You asked the Plan to pre-approve Nexletol Tablet (J8499). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under Medicare 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 pre-approve Nexletol Tablet.
Benefits for Nexletol Tablet (J8499) 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the analysis and report of an external EKG
recording provided on December 20, 2019.
You asked the Plan to waive the copayment for the EKG recording analysis and report. You say that you never
saw the provider and that you were given the device at your primary care physician's office. The Plan denied
your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for basic radiological services at an in-network specialist's office.
You have been asked to pay a $50 copayment for the EKG recording analysis and report. The EKG recording
analysis and report falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The record shows this is a remote service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the analysis and report of an external EKG recording
provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on January 24, 2019.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like reconsideration because the billed supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder elbow wrist hand orthosis have not been met. Specifically, the record does not contain sufficient documentation of the member's medical condition to substantiate the necessity for the items billed. Of note, the file shows that the Plan requested documentation to validate an established relationship with the ordering physician along with documentation of the duration of the member's condition, clinical course (worsening or improving), prognosis, nature and extend of functional limitations, other therapeutic interventions and results and previously purchased DME items related to the billed items. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on January 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on April 16,
2020.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told there would
be no cost for the injection. 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 20%
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs
used during outpatient diagnostic procedures.
You have been asked to pay $141.22 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $706.11. ($706.11 x 20% = $141.22). The Part B 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 coinsurance for the Part B injection
provided on April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Computed Tomography (CT) of the chest
and abdomen (71250, 74150) provided February 20, 2020.
You asked the Plan to waive the copayments for the CT scan. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct copay was 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 $50
copayment for Advanced Imaging Services.
You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the Advanced Imaging
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 Computed Tomography
(CT) of the chest and abdomen (71250, 74150) provided February 20, 2020.