Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the thorax (71250-26) 
provided on October 21, 2021. 
 
You asked the Plan to pay for the CT scan. You say that this claim is supported in the medical record and was 
denied incorrectly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 3, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) of the thorax (71250-26) 
provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from May 3, 
2022, through May 5, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from May 3, 2022, through May 5, 2022.  Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
only have a copay of $250. You also say that you did not call the ambulance, and did not go to the hospital. 
The Plan denied your request. The Plan says this service is not covered. 
 
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 April 13, 2022. 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 the ambulance response and treatment with no 
transport (A0998) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the treatment received was 
medically necessary for the member. The Plan denied your request. The Plan says the services were not ordered 
or performed by an in-network provider. The Plan also says that there as invalid or missing information. 
 
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 a domiciliary or rest home visit provided on June 
14, 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 copayment for ear, nose, and throat specilist follow up 
provided on April 25, 2022. 
 
You asked the Plan to waive the copayment for ear, nose, and throat specilist follow up. You say that you 
thought that follow ups for surgery were covered without 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 $40 
copayment for CFR. 
 
 
 
 
 
 You have been asked to pay a $40 copayment for ear, nose, and throat specilist follow up. This item/service 
falls within the CFR 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 ear, nose, and throat 
specilist follow up provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that the lab tests rendered to the enrollee do not require a 
prior authorization. You also say that the enrollee is not made aware of which lab the samples are sent to and 
has no choice of network status. The Plan denied your request. The Plan says the rendering provider and 
referring provider are both out-of-network. The Plan also says there is no evidence to support that the lab 
services were urgent nor emergent. 
 
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 services provided on September 17, 2021, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various outpatient services received from January 5, 2022, to 
March 8, 2022. 
 
You asked the Plan to pay for the services. You say that you should not be responsible for the cost-sharing 
because all of the claims are for services related to COVID. The Plan denied your request. The Plan says the 
copayments were applied appropriately. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay 10% coinsurance for in-network outpatient services.  
 
 
 
 
 
 
 The enrollee has been asked to pay 10% coinsurance for each of the services. The services fall within the in-
network outpatient services 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 pay for various outpatient 
services received from January 5, 2022, to March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus Test Strips. You say that you would like 
reconsideration because you already use this brand and would prefer to continue with it. The Plan denied your 
request. The Plan says you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 We looked at the file and Medicare rules. Accu-Chek Aviva Plus test strips require approval before they are 
covered at a retail pharmacy. The file does not include any documentation from your physician documenting 
why you require this specific brand of test strips. Without this, medical necessity cannot be established. Based 
on this information, we decided that Medicare rules for coverage of Accu-Chek Aviva Plus Test Strips have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair (E0240) and a raised toilet seat (E0244) 
provided on April 4, 2022. 
 
You asked the Plan to pay for a shower chair and a raised toilet seat. You say that you would like these services 
reconsidered, because you had hip replacement and need this raised toilet seat for your after-care process. The 
Plan denied your request. The Plan says the requested items are not covered because they are not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a raised toilet seat 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 pay for a shower chair 
(E0240) and a raised toilet seat (E0244) provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 March 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
received on May 24, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you do not understand 
why you must pay a copayment. The Plan denied your request. The Plan says the copayment was 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 $45 
copayment for a medical eye examination.  
 
You have been asked to pay a $45 copayment for a medical eye examination. The services at issue falls within 
the Medicare-covered vision 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 a 
medical eye examination (92014) received on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
 
 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 May 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99326), nail debridement 
(11721), and a biopsy of the nail unit (11755) provided on February 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit, nail debridement and nail biopsy services. You 
say that the services rendered to the enrollee were medically necessary. The Plan denied your request. The Plan 
says the services were rendered by an out-of-network provider. The Plan says care from out-of-network 
providers is only covered in cases involving emergencies, out of area urgent care, or pre-approved care. The 
Plan determined that the services were neither urgent nor emergent and no prior authorization was obtained. 
 
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 a domiciliary or rest home visit (99326), nail 
debridement (11721), and a biopsy of the nail unit (11755) provided on February 16, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for influenza virus vaccine services provided on September 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for influenza virus vaccine services. You say that you went to this facility in 2020, 
and the provider did not question your Plan, so you assumed all was okay. The Plan denied your request. The 
Plan says services were rendered without a referral or prior authorization from your primary care physician 
(PCP). 
 
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 influenza virus vaccine services provided on 
September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on June 27, 2022, 
and June 29, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that the Plan's website indicated that 
you could be reimbursed for the COVID-19 tests that you purchased. The Plan denied your request. The Plan 
says COVID-19 home test kits are not eligible benefits through your Medicare Advantage plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits are an OTC item. The Plan does not offer a supplemental benefit covering this service, as 
this is not currently required by Medicare. However, for future purchases, these can be obtained with 
participating providers and covered by Original Medicare when using your Medicare card rather than your Plan 
card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on June 27, 2022, 
and June 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound and mammogram provided 
on April 21, 2022. 
 
You asked the Plan to waive the copayments for an ultrasound and mammogram. You say that this should be 
covered. The Plan denied your request. The Plan says the copayments applied are 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 $125 
copayment for diagnostic radiology services and $50 copayment for outpatient diagnostic tests.  
 
 
 
 
 You have been asked to pay $175 ($125 + $50) copayment for an ultrasound and mammogram. Ultrasounds 
and mammograms fall 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 copayments for an ultrasound and mammogram provided on 
April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational as it 
has not been shown to be safe and effective in long term studies. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chair car transport you received on March 27, 2022. 
 
You asked the Plan to pay for the chair car transport. You say that you should be reimbursed for this service. 
The Plan denied your request. The Plan says chair car transport is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for chair car transport services.  
 
The services you have asked the Plan to pay for are chair car transport services. Therefore, we decided that the 
Plan does not have to pay for chair car transport you received on March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
(0275T) procedure. 
 
You asked the Plan to pre-approve the MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee is not participating in an 
approved clinical study for evidence development. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, the enrollee is not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve the minimally 
invasive lumbar decompression (MILD) (0275T) procedure.