Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided by a participating 
provider on January 9, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you saw this doctor last year and 
you didn't have to pay this much. The Plan denied your request. The Plan says the correct deductible amount 
has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for physician/practitioner services/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $500 deductible for physician/practitioner services/out-of-network. This cost sharing 
is a contractual obligation that had not been met at the time an office visit was received on January 9, 2020. 
The total amount you are being asked to pay is $ 77.59. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided by a participating provider on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5260) provided on March 11, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because the Plan 
has reimbursed you for hearing aids in the past. The Plan denied your request. The Plan says these hearing aids 
were purchased from an out of network provider. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only.  
 
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 hearing aids. Our reviewer says that  Our 
physician reviewer found  
 
We looked at this physician's review, the file, and the Plan's rules. 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 hearing aids (V5260) provided on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of a PET/CT scan provided on March 5, 
2020. 
 
You asked the Plan to pay for the PET scan interpretation. You say that this is billed correctly and should be 
paid. The Plan denied your request. The Plan says this claim was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes that may be used. 
 
Diagnosis C56.9 is not listed as an appropriate diagnosis code for PET imaging. The affected side must be 
specified. Therefore, we decided that the Plan does not have to pay for the interpretation of a PET/CT scan 
provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
January 23, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for a consultation with a specialty physician.  
 
You have been asked to pay a $15 copayment for the consultation provided by a specialty physician. 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 (99214) provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 1, 
2020. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was provided following an unsolicited outreach call. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator 
(E0745) provided on May 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 10, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you always just had to pay 
your office visit copayment. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $300 copayment for an outpatient surgery. The injection that was provided is 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on February 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an 
inpatient skilled nursing facility admission. 
 
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 pre-approve SNF care. Our reviewer says that an 
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the 
enrollee does not require skilled nursing or skilled therapy services on a daily basis in a skilled nursing facility. 
As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on September 6, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are 
non-covered. 
 
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. 
Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the CYP panel rendered on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on February 7, 2020 from an in-
network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that the Plan should have paid another $196.50 towards 
the glasses. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 
EOC benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. You purchased the eyewear from an in-network provider for 
your plan and network. The provider filed the claim and your liability should be $342.60 at the point of 
purchase, after your benefits were applied. Therefore, you will remain liable for the cost share associated to 
eyewear purchased on February 7, 2020 because you cannot combine any promotional offers with our vision 
benefit. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on February 7, 
2020 from an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on December 3, 2019 by an 
out of network provider. 
 
You asked the Plan to pay for the podiatry services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items/services at issue in this appeal. 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 podiatry services provided on December 3, 2019 by an out of 
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services and an oral appliance provided from June 6, 
2019 to July 31, 2019 related to TMJ. 
 
You asked the Plan to pay for an oral appliance and/or treatment related to temporomandibular joint (TMJ) 
syndrome. You say that you are not satisfied with how these claims were processed. The Plan denied your 
request. The Plan says only those dental services not directly related to TMJ could be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary. Based on the records provided, the rules for coverage of an oral appliance and/or treatment related to 
temporomandibular joint (TMJ) syndrome were not met. The records show general TMJ is the diagnosis. The 
records do not show TMJ is a secondary condition or the result of a primary medical diagnosis or condition. 
We note the Plan paid for those dental services that were eligible for payment. Therefore, we decided that the 
Plan does not have to pay for dental services and an oral appliance provided from June 6, 2019 to July 31, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 12, 2020. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization for 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items/services at issue in this appeal. 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 out of network physician services provided to the enrollee on 
February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair purchased on February 28, 2020. 
 
You asked the Plan to pay for this wheelchair. You say that this wheelchair should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for a wheelchair and there are no 
medical records submitted to show you met the required coverage criteria for a wheelchair at the time of 
purchase. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment may require prior authorization. You did not have prior authorization to 
purchase or rent a wheelchair. The appropriate medical records to show a manual wheelchair was necessary in 
the home were not submitted prior to purchase. 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 a wheelchair purchased on 
February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient mental health care provided on 
March 9, 2020. 
 
You asked the Plan to waive the deductible for outpatient mental health care. You say that you disagree with 
the charges because you already met the deductible amount. 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient mental health care.  
 
You received outpatient mental health care on March 9, 2020. The record shows that you had only paid 
$160.70 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the 
total allowed amount of $337.21. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible for outpatient mental health care. This cost sharing is a contractual obligation that had not been 
met at the time outpatient mental health care was received on March 9, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for outpatient mental health care provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Inogen portable oxygen concentrator. 
 
You asked the Plan to pre-approve a Inogen portable oxygen concentrator. You say that the items 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. Medicare rules say that the RUL for oxygen equipment is 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Inogen portable oxygen concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Inogen portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vaccines provided to the enrollee on March 2, 2020. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that this claim should be 
paid. The Plan denied your request. The Plan says payment for preventative vaccines should be submitted to 
the enrollee's Medicare Part D carrier at the time of service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules. Records do not show that you have been 
injured or directly exposed to any illness related to preventative vaccines under Medicare Part B. Therefore, we 
decided that the Plan does not have to pay for vaccines provided to the enrollee on March 2, 2020.  
 
Benefits for preventative vaccines may be available under the Medicare Part D Benefit. Please contact the 
enrollees Part D carrier for further information.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve skilled nursing visits. You say that this is necessary to prevent weekly 
hospital visits. The Plan denied your request. The Plan says you do not have skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing visits. Our reviewer says 
that the requested home health care is not medically necessary. Our physician reviewer found skilled nursing 
services are not required to effectively provide treatment, care, or services in order to improve your condition, 
or to establish/perform a maintenance program to maintain your condition or prevent deterioration. Your needs 
do not require a skilled professional nurse. There is no complex wound care or other skilled nursing need. You 
have been educated in disease and medication management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair, multiple power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds with tilt/recline, elevating leg rests, and 
skin protection seat cushion. 
 
You asked the Plan to pre-approve a replacement power wheelchair (K0843). You say that the enrollee is 
unable to use the current wheelchair because of a medical condition. The Plan denied your request. The Plan 
says the documents provided do not show the enrollee's needs are no longer met by the current wheelchair or 
the current wheelchair can't be repaired or modified to meet the needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 replacement power wheelchair. Our 
reviewer says that the requested power wheelchair and options are not medically necessary. Our physician 
reviewer found the requested PMD- K0843 with elevating leg rests E1012, tilt and recline E1007, and skin 
protection wheelchair seat cushion E2623 is not medically necessary. The documentation does not reveal that 
the enrollee's current MRADLS are unable to be met with the current power wheelchair. Furthermore, the 
documentation from the enrollee's treating practitioner is conflicting on the review of systems of the enrollee's 
functional status. It is not clear that the enrollee is unable to ameliorate his current condition with an 
appropriately fitted walker or manual wheelchair as the April 14, 2020 and June 4, 2020 progress notes both 
state no muscle weakness, joint pain, or gait dysfunction. The enrollee's upper extremity strength is near 
normal. The June 4, 2020 progress note states both difficulty walking and then no difficulty walking. The 
documentation does not support the need for the requested PMD. 
 
 
 
 
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 replacement power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Group 2 heavy duty power wheelchair and accessories.