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

 
We decided that the Plan does not have to reimburse you under the Pick Your Perks reimbursement program 
for the copayment for prescriptions provided on November 3, 2021. 
 
You asked the Plan to reimburse you under the Pick Your Perks reimbursement program for the copayment for 
prescriptions. The Plan denied your request. The Plan says based on the members benefit plan and the Pick 
Your Perks program, prescription copays are not a covered and ineligible for reimbursement. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says reimbursement of 
up to a maximum of $550 per calendar year for your out-of-pocket costs of purchasing Medicare approved 
supplemental benefits. 
 
We looked at the file and the Plans rules. The file shows that copayments are not covered Pick Your Perks 
reimbursement program benefit. Therefore, we decided that the Plan does not have to reimburse you under the 
Pick Your Perks reimbursement program for the copayment for prescriptions provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that your handrail is in place, although you still almost 
fall on your stairs. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Additionally, the same 
monitor was last received on 12/3/20. It cannot be covered again this soon. Based on this information, we 
decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport. 
 
You asked the Plan to pre-approve ambulance service, basic life support, non-emergency transport. The Plan 
denied your request. The Plan says the member's diagnosis is confusion/encephalopathy exacerbated by 
COVID-19. Per the member's medical record, the member is not bed-confined. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that ambulance service, basic life support, non-emergency 
transport is not medically necessary. Our physician reviewer found that the documentation does not support 
that other means of transport (such as stretcher van) were contraindicated. The documentation does not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide for safe transport. The documentation does not support that the ambulance 
transport was medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pre-approve ambulance service, basic life support, 
non-emergency transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Completed studies say that this procedure does not improve outcomes compared to standard treatment of SI 
joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, is 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lenses (V2744, V2750, V2781, V2784) 
purchased on October 11, 2021. 
 
You asked the Plan to pay for the lenses. You say that your sight changes frequently, and you needed a new 
prescription. The Plan denied your request. The Plan says you previously received covered lenses in October 
2020. Routine eyewear is only covered once every two years. 
 
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. The Plan covers these services once every two years. Additional lens options including tinting, anti-
reflective coating and polycarbonate are not covered. 
 
We looked at the file and the Plan's rules. The record shows that you previously received routine lenses less 
than two years before the date in question, and therefore your benefit had been exhausted before the date in 
question. In addition, some of the lens options purchased on October 11, 2021, are not covered by your 
supplemental benefit under any condition. Based on this information, we decided that the Plan's rules for 
coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglass lenses (V2744, V2750, V2781, V2784) purchased on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on June 18, 2021. 
 
You asked the Plan to pay 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 service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 18, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on October 1, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that fell in the garage 
and could not get up. You say that you were not able to call for help and a neighbor saw you lying on the floor 
and called 911. You say when the ambulance arrived, they helped you up and into your house and did an 
electrocardiogram (EKG) and they recommended you go to hospital by ambulance transport, but you did not 
feel it was necessary to go to hospital and declined. The Plan denied your request. The Plan says Medicare 
ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, and then there is no 
Medicare-covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for the visual field examination. We decided that the Plan 
does not have to reduce the copayment for the ophthalmology services.  
 
You asked the Plan to reduce the copayment for the visual field examination. You say that you would like 
reconsideration because you should only be responsible for a $40 copayment for these services. The Plan says 
that you have a $50.00 copay for Medicare-covered vision and are responsible for any other charges outside the 
co-payment and not covered under your co-pay. 
 
We decided that the Plan has to hold you harmless for the visual field examination.  
 
The Plan follows Medicare rules. Medicare rules say that a contract plan provider is an agent of the plan. 
Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the 
services will not be covered. 
 
We looked at your request, the file and Medicare rules. Based on this information, we have determined that the 
Plan must hold you harmless for the visual field examination. The record indicates that you received a 
Medicare covered eye exam. Additionally, you received this service from an in-network provider. There is no 
indication that the visual field assessment, which is a part of the Medicare covered eye exam, would not be 
covered. Therefore, we decided that the Plan has to hold you harmless for the visual field examination.  
 We also decided that the Plan does not have to reduce the copayment for the ophthalmology services. 
 
The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, 
accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find 
this rule at 42 CFR Section 422.111(a) and (b). 
 
We looked at your request, the file and Plan rules. Based on this information we have determined that the 
copayment assessed by the Plan is correct. You have been asked to pay a $50 copayment for Ophthalmology 
services. Your contract with the Plan verifies that this is the correct copayment for Medicare covered vision 
services. Therefore, we decided that the Plan does not have to reduce the copayment for the ophthalmology 
services. 
 
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 electrical stimulation (97014) provided September 7, 2021 to
September 20, 2021.
You asked the Plan to pay for the chiropractic services. You say that the provider did not tell the enrollee that
there would be a charge for this treatment. If they had she would not have done it as she has limited income.
The Plan denied your request. The Plan says this service is not covered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for electrical stimulation (97014) provided September 7, 2021 to September 20,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you under the Pick Your Perks reimbursement program 
for RAW Probiotics Ultimate Care (Garden of Life) provided on October 25, 2021. 
 
You asked the Plan to reimburse you under the Pick Your Perks reimbursement program for RAW Probiotics 
Ultimate Care (Garden of Life). The Plan denied your request. The Plan says based on the members benefit 
Plan and the Pick Your Perks program for 2021, RAW Probiotics Ultimate Care (Garden of Life) is not a 
covered over-the-counter supplement. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says ineligible items 
include but are not limited to the following: Alternative medicines such as botanicals, herbals, probiotics and 
nutraceuticals. 
 
 We looked at the file and the Plans rules. The file shows that over-the-counter items must be included on the 
Plans allowed items list. Ineligible items include but are not limited to the following: Alternative medicines 
such as botanicals, herbals, probiotics and nutraceuticals. Therefore, we decided that the Plan does not have to 
reimburse you under the Pick Your Perks reimbursement program for RAW Probiotics Ultimate Care  
(Garden of Life) provided on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress. 
 
You asked the Plan to pre-approve the hospital bed and mattress. The Plan denied your request. The Plan says 
the coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a hospital bed/mattress are covered for the indications 
established in the applicable LCD. 
 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 hospital bed and mattress. Our 
reviewer says that the requested hospital bed and mattress are not medically reasonable and necessary. Our 
physician reviewer found that the provided records report the hospital bed is requested to create a safer 
environment for the enrollee due to right-sided weakness from a prior stroke with fall risk. The provided 
records, however, do not clearly document any of the required criteria established in the applicable LCD. 
 
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 hospital bed and mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed and mattress.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for skin grafting of the face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services (15120, 14041)
rendered on August 3, 2021.
You asked the Plan to waive the coinsurance for skin grafting of the face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits surgical services. You say that you were told the hospital
accepts this Plan as full payment and now you received a bill for over $3,000.
You also say you are a 74 year old disabled female on disability and cannot afford this. The Plan denied your
request. The Plan says you were 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%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay $556.81 in coinsurance, which is 50% of the allowed amount for skin grafting of
the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits surgical services
($1,113.63 allowed amount x 50% = $556.81). Skin grafting of the face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits surgical services fall within the outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers 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 skin grafting of the face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits surgical services (15120, 14041) rendered on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not reimbursable as a separate charge.      
 
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 83789 is "Mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen." 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code cannot be 
separately reimbursed when billed for specimen validity testing on specimens used for drug testing. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code cannot be 
separately reimbursed when billed for specimen validity testing on specimens used for drug testing. 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 drug testing services provided to the enrollee on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on September 6, 
2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (0242U) provided on September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for perfusion services (86891, 99190, 99191, P9022) provided 
on September 22, 2021. 
 
You asked the Plan to pay for perfusion services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not separately payable from the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. The services at issue were nonphysician services furnished to an 
inpatient. These services must be billed through the hospital. Based on this information, we decided that 
Medicare rules for coverage of perfusion services have not been met. Therefore, we decided that the Plan does 
not have to pay for perfusion services (86891, 99190, 99191, P9022) provided on September 22, 2021.