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

 
We decided that the Plan does not have to pay for hearing aid (V5257), dispensing fee, monaural hearing aid 
(V5241) and ear mold/insert (V5264) provided on November 13, 2018. 
 
You asked the Plan to pay for hearing aid, dispensing fee and ear mold/insert. You say that the service should 
be covered. The Plan denied your request. The Plan says you have exhausted the maximum allowed for this 
benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The plan covers one 
hearing aid every three years with up to a $500 limit. 
  
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aid, dispensing fee and ear mold/insert have not been met. Specifically, the cost of these 
services exceeded the $500 allowance. This means you are responsible for the difference. Therefore, we 
decided that the Plan does not have to pay for hearing aid (V5257), dispensing fee, monaural hearing aid 
(V5241) and ear mold/insert (V5264) provided on November 13, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intra-articular injection, 1 mg (J7318) and 
arthrocentesis, aspiration and/or injection, major joint or bursa, without ultrasound guidance (20610) provided 
July 24, 2020. 
 
You asked the Plan to waive the copayment for the injection and physician services. You say that you think the 
provider is over charging and the whole bill should be $450. The medication should not be $4500 The Plan 
denied your request. The Plan says this claim was processed and the correct copayment was applied per the 
plan 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs and $35 copayment per visit to a specialist.  
 
You have been asked to pay $485.00 ($2,250 x 20% = $450 + $35 $485.00) for the injection and physician 
services. the injection and physician services falls within the Medicare Part B prescription drugs and 
Physician/Practitioner services, including doctor's office visits 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 intra-articular injection, 1 mg (J7318) and arthrocentesis, aspiration and/or 
injection, major joint or bursa, without ultrasound guidance (20610) provided July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have   
 
You asked the Plan to pay for genetic testing provided to the enrollee. You say that this testing was medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is no physician order and there is 
no physician attestation that the ordering provider is licensed to order the selected test(s). The records provided 
do not support this testing was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate documentation. In this case there is insufficient physician 
documentation and medical record documentation to show the enrollee met the criteria required for this testing 
at the time of service. Medicare coverage criteria were not met. Therefore, the Plan does not have to pay for 
genetic testing provided to the enrollee on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2020 by a non-
network provider. 
 
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 were rendered by a non-network provider without 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 referring provider 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 laboratory services provided on May 26, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on June 11, 2020. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that shipping documentation or delivery confirmation documentation was not provided. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the knee orthosis provided on June 11, 2020.
Appeal type: Lab
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 April 2, 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 the enrollee by an out-of-network provider 
on April 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from 
August 7, 2020 through August 9, 2020. 
 
You asked the Plan to waive the copay for the inpatient hospital services. You say that you should not be 
responsible for the copay. The Plan denied your request. The Plan says that the copay you are being charged is 
correct. 
 
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 $360 
copay per day for days 1-5 of inpatient hospital care.  
 
You have been asked to pay a $360 copay for the inpatient hospital services. The inpatient hospital services fall 
within the days 1-5 of inpatient hospital care 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 copay for 
the inpatient hospital services provided from August 7, 2020 through August 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the finger x-ray (73140) provided on June 28, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because this service was 
denied as a duplicate in error. The Plan denied your request. The Plan says this service was previously 
processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the x-ray have not been met. Specifically, the record indicates that this is a duplicate claim for CPT 
code 73140 which was previously processed and paid to the billing provider. Therefore, we decided that the 
Plan does not have to pay for the finger x-ray (73140) provided on June 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says the enrollee is 
able to currently complete all of her activities of daily living. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The file shows that the requested scooter has added capabilities that are not needed for use in the home. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after 
December 11, 2020. 
 
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 continued SNF coverage. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found you had stable vital signs. You 
required stand-by assistance to contact guard/minimal assistance with functional mobility including walking 
short distances with a rolling walker. The documentation does not support that you require the specialized 
skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing 
or skilled therapy services are required on a daily basis. As a practical matter, you no longer require the 
necessary services on an inpatient basis, at a SNF 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 continued SNF coverage have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) coverage after December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay and inpatient 
rehabilitation stay provided from July 1, 2019, through July 5, 2019 and July 5, 2019, through July 13, 2019. 
 
You asked the Plan to waive the copayment for the inpatient stay and inpatient rehabilitation stay. You say that 
you should not be billed for an inpatient hospital stay. You say that your copayment should be $0. The Plan 
denied your request. The Plan says the copayments 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 $325 
copayment per day, days 1 to 5 at an in-network inpatient hospital. Your inpatient cost share will begin on day 
one each time you are admitted or transferred to a specific facility type, including inpatient rehabilitation 
facilities, long term acute care (LTAC) facilities, inpatient acute care facilities, and inpatient psychiatric 
facilities. 
 
You have been asked to pay a total of $2,925 for the inpatient stay and inpatient rehabilitation stay.  
 
Date of Service Service Standard Copayment Member Liability 
July 1, 2019- 
July 5, 2019 
Inpatient Stay $325/Day, Days 1-5 $1,300 
July 5, 2019- 
July 13, 2019 
Inpatient Rehabilitation Stay $325/Day, Days 1-5 $1,625 
TOTAL:   $2,925 
 
The inpatient stay and inpatient rehabilitation stay falls within the "Inpatient hospital care" benefit category. 
The records show that both stays were billed as inpatient. 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 inpatient stay and inpatient rehabilitation stay provided from July 1, 2019, through July 5, 2019 and July 
5, 2019, through July 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on June 24, 2020.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 71045 is radiologic examination, chest; single view.

We find that CPT code 71045 is not supported in the medical record. Specifically, Z diagnosis code can be used in any healthcare setting but can only be reported as principal diagnosis in an inpatient setting. These codes are not procedure codes and a corresponding procedure code must accompany a Z code to describe any
procedure performed. The Z01 family of codes indicate that an encounter for other special examination without complaint suspected or reported diagnosis.
This procedure code was billed with only the diagnosis code Z01.89 (Encounter for other specified special examinations). This code should be reported for routine laboratory/radiology testing in the absence of any signs or associated diagnosis. Since services were rendered in Emergency Room, an outpatient non-routine setting, code Z01.89 should be accompanied by the corresponding procedure code. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
August 4, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were not advised that 
the x-rays would not be covered. You also say that you cannot afford to pay for this. The Plan denied your 
request. The Plan says this service is not covered by the Plan. 
 
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 
complete series of intraoral x-rays (D0210) provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre reader and sensors. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the provider indicated that you are not using insulin injections 3 or more times a 
day, and not testing your blood glucose at least 4 times daily. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has not provided any 
medical records to support their denial. It cannot be determined if the enrollee meets the criteria for a 
continuous glucose monitor. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre reader 
and sensors.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot/cold packs therapy rendered from January 13, 2020 to 
January 31, 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 procedure code 97010 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. The services at issue are hot/cold packs therapy billed with code 
97010. This code has a status indicator of B and no separate Medicare payment. Therefore, we decided that the 
Plan does not have to pay for the hot/cold packs therapy rendered from January 13, 2020 to January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient behavioral health services 
provided July 30, 2020, to August 5, 2020. 
 
You asked the Plan to waive the copayment for the inpatient behavioral health services. You say that you 
thought you were only responsible for $350 only once as an inpatient no matter how many days you stayed. 
Now you're told that mental inpatient is $300 for each day for the first 4 days. The Plan denied your request. 
The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $300 
copayment per day for days 1-4 for Inpatient mental health care.  
 
You have been asked to pay $1,200 for the inpatient behavioral health services. The inpatient behavioral health 
services fall within the Inpatient mental health care 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 inpatient behavioral health services provided July 30, 2020, to August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided August 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for these services. 
 
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 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 specialist services provided August 6, 2020 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay from June 
12, 2020, to June 26, 2020. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you were told that 
this was a skilled nursing facility stay and the enrollee would not be charged a copayment. The Plan denied 
your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $345 copayment for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient rehabilitation stay from June 12, 2020, to June 26, 2020. An inpatient 
rehabilitation stay is not a skilled nursing facility stay. Therefore, the enrollee is responsible to pay a $345 
copayment for days 1-5 (June 12, 2020, to June 16, 2020). $345 (copayment) x 5 (inpatient days) = $1,725.  
 
The enrollee has been asked to pay the total copayment amount of $1,725 for an inpatient rehabilitation stay. 
An inpatient rehabilitation stay falls within the inpatient hospital care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient rehabilitation stay from June 12, 2020, to June 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED visit and wound repair provided on June 30, 2020. 
 
You asked the Plan to pay for the ED visit and wound repair. You say that the enrollee's injuries were unrelated 
to their hospice care. The Plan denied your request. The Plan says these services must be billed to Original 
Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ED visit and wound repair provided on June 30, 2020.