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

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a x- ray and a specialist office visit 
provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for a x- ray and a specialist office visit. You say that you do not 
agree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment in network outpatient diagnostic tests/outpatient X-ray and a $35 copayment for and in network 
Physician/Practitioner services/specialty care physician.  
 
You have been asked to pay a $10 copayment and a $35 copayment for a x- ray and a specialist office visit. 
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 a x- ray and a specialist office visit provided on March 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a coronavirus (COVID-19) office visit. You 
also say that COVID-19 related services are exempt from in-network or out-of-network participation and do 
not require any authorization. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 an office visit provided on January 12, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialty absorptive dressing and gauze 
provided on March 17, 2022, and May 15, 2022. 
 
You asked the Plan to waive the coinsurance for specialty absorptive dressing and gauze. You say that you 
believe you were charged these amounts in error. The Plan denied your request. The Plan says this cost sharing 
was charged 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies. The allowed amounts of these 
supplies total $452, resulting in a total coinsurance amount of $90.40. 
 
You have been asked to pay 20% coinsurance for specialty absorptive dressing and gauze. This item/service 
falls within the Durable medical equipment (DME) and related supplies 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 specialty absorptive dressing and gauze provided on March 17, 
2022, and May 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (99199 x2) provided on June 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were never advised you needed to see an in-
network provider. You also say that you have been seeing the provider you were treated by for well over 15 
years. The Plan denied your request. The Plan says you are responsible for the deductible and copayment that 
applied. 
 
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 when they are purchased through a Plan approved hearing aid vendor.  
 
 
 
 
 
 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. The record shows that these hearing aids 
were purchased from an out-of-network provider, and the Plan incorrectly allowed payment on the claim. 
However, the Plan is not retracting the payment, as it would be a detriment to you. Therefore, we decided that 
the Plan does not have to pay for the hearing aids (99199 x2) provided on June 7, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals (S5170). 
 
You asked the Plan to pre-approve home delivered meals. You say that these meals will be important to your 
ongoing recovery and health. The Plan denied your request. The Plan says this benefit has been exhausted.  
The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be offered as a 
supplemental benefit. 
 
We looked at the file and Medicare rules. The contract clearly states that the Plan covers up to two meals per 
day in a consecutive four-week period, once per calendar year. The record shows that, although you do have a 
history of congestive heart failure, you accepted meal services on June 23, 2022, and received all four 
deliveries, exhausting this benefit. Based on this information, we decided that Medicare rules for coverage of 
home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-approve 
home delivered meals (S5170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you thought you had out-of-network coverage. 
You say that you are struggling financially, and you would like the claims to be paid. The Plan denied your 
request. The Plan says an authorization was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 laboratory services provided on May 4, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visits provided on May 26, 2022, 
and June 01, 2022. 
 
You asked the Plan to waive the coinsurance for office visits. You say that you are disputing the charges. The 
Plan denied your request. The Plan says this cost sharing was charged 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 40% 
coinsurance for Physician/Practitioner services, including doctors office visits. The allowed amounts of these 
office visits total $409.56, resulting in a total coinsurance amount of $163.82. 
 
You have been asked to pay 40% coinsurance for out of network office visits. This item/service falls within the 
Physician/Practitioner services, including doctors 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 coinsurance for office visits provided on May 26, 2022, and June 01, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code 99601. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories. 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that power wheelchair accessories are being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve power wheelchair accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI provided on June 9, 2022, and June 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an MRI. You say that you were referred and you appealing reconsideration of 
payment for the magnetic resonance imaging services. The Plan denied your request. The Plan says an 
authorization was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 an MRI provided on June 9, 2022, and June 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance a sleep study provided on May 20, 2022. 
 
You asked the Plan to waive the coinsurance a sleep study. You say that you believe that the sleep study was 
not professional. The Plan denied your request. The Plan says this cost sharing was charged 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 15% 
coinsurance for in-network outpatient diagnostic tests and therapeutic services/Medicare-covered non-
radiological diagnostic services.  
 
You have been asked to pay 15% coinsurance for a sleep study. You are being asked to pay is $957.99 for the 
sleep study. The total amount you are being asked to pay is $143.70($957.99 x 15% = $143.70). 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 a sleep study provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing on May 10, 2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that you feel you should not have a cost 
share and your lab work should be covered under your benefits. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $40 
copayment for Medicare-covered diagnostic lab services at providers office, network hospital/non-JVHL, 
Quest Diagnostics Lab or LabCorp. Covered services include but are not limited to laboratory tests. The 
provider billed in the amount of $15.53 and the allowed amount is $1.50. The provider also billed in the 
amount of $24.15 and the allowed amount is $4.86. $1.50 + $4.86 = $6.36. This is less than the copayment 
amount. Therefore, results in the total cost sharing amount of $6.36. 
 
 
 You have been asked to pay a $6.36 copayment, which is less than the copayment for lab testing. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 lab testing on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test (87426) and sales tax (S9999) 
purchased on January 14, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test and sales tax. You say that you purchased this 
COVID-19 test prior to them being supplied through the pharmacies for free, and would like to be reimbursed. 
The Plan denied your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
 
 
 We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the at-home COVID-19 test (87426) and sales tax (S9999) purchased on 
January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on June 08, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for annual wellness visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 annual wellness visit provided on June 08, 2022, 
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 inpatient hospital care provided March 25, 
2022, to April 3, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that your husband talked to the 
plan, and they said it would be affordable. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $200 
copayment per day for days 1 to 7 and $0 unlimited additional days. for inpatient hospital care.  
 
You have been asked to pay a $200 copayment per day for days 1 to 7 and $0 unlimited additional days for 
inpatient hospital care. The total amount you are being asked to pay is $1,400 ($200 x 7 visits = $1,400). 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 inpatient hospital care provided March 25, 2022, to April 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that services were rendered in good faith and were medically 
necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 lab work provided on April 1, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 20, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telemedicine visits provided from 
April 8, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for specialist telemedicine visits. You say that you feel that you 
should not have to pay a $45 copayment every single month. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $45 
copayment per visit for Physician/Practitioner services/specialist telemedicine visit.  
 
You have been asked to pay a $45 copayment per visit for specialist telemedicine visits. The total amount you 
are being asked to pay is $90 ($45 x 2 visits = $90). 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 
specialist telemedicine visits provided from April 8, 2022, to May 27, 2022.