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

We decided that the Plan does not have to pay for the wig (A9282) provided on May 15, 2021. 
 
You asked the Plan to pay for the wig. You say that the wig is necessary for your hair loss caused by 
chemotherapy treatments. The Plan denied your request. The Plan says wigs are not covered by Original 
Medicare, and the Plan does not offer a supplemental benefit to cover wigs. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282) 
provided on May 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.

You asked the Plan to pre-approve these services. You say that this procedure is covered by Medicare and should be covered by the Plan. The Plan denied your request. The Plan says that this is not felt to be a safe and effective treatment for this patient.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 19, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 25, 2021, to May 28, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 25, 2021, to May 28, 2021. Therefore, you are responsible to pay 
a $275 copayment for days 1-3 (May 25, 2021, to May 27, 2021).  
The total amount you owe is: $275 (copayment) x 3 (inpatient days) = $825.  
 
You have been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient 
hospital stay falls within the 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 
copayment for an inpatient hospital stay provided from May 25, 2021, to May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
November 28, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue.  
 
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for out of network physician services provided to the enrollee on November 28, 
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 6 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 6 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 6 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions (D7321).
You asked the Plan to pre-approve these services. You say that the broken pieces of teeth should have been extracted as well when your teeth were extracted. The Plan denied your request. The Plan says that this 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 pre-approve alveoloplasty not in conjunction with extractions (D7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on May 25, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says the service 
or item in question is not covered under the member's contract under any normal circumstances. 
 
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 pays for 
hearing aids only provided by the Plan's hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
May 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 16, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you don't feel as though you received 
any treatment.  You said that you just had blood work done and you don't think you should be billed for this. 
The Plan denied your request. The Plan says you were charged this copayment 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 $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the extent 
of services you receive in the ER. 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 emergency room 
(ER) visit you had on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection procedure for the sacroiliac joint.

You asked the Plan to pre-approve injection procedure for the sacroiliac joint. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that 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 injection procedure for the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee failed to achieve greater than 75% pain relief and the physical exam is deficient, in that only one test was documented. The request for therapeutic injection is deemed not medically reasonable or 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 injection procedure for the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for the sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided by 
an out-of-network provider on June 21, 2021. 
 
You asked the Plan to pay for bitewings. You say that you do not know why you received a denial for 
preventative care. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
 
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. These services were provided by an out-of-network provider. Out-of-
network provider services are not a covered benefit. Therefore, we decided that the Plan does not have to pay 
for bitewings - four radiographic images (D0274) provided by an out-of-network provider on June 21, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomography (CT) guidance for placement of radiation
therapy fields (77014) provided on April 5, 2021, through April 9, 2021.

You asked the Plan to pay for the CT guidance. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that the code 77014 is considered incidental
when performed within 60 days before or after the date of service 77301 was performed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 77014 is supported in the medical record. Specifically, there is no Medicare guidance to
indicate that CPT code 77014 is considered incidental when performed within 60 days before or after the date
of service when CPT code 99301 was performed. It is the burden of the Health Plan to substantiate their denial
with evidence. The Plan has not provided any evidence as to why CPT code 77014 is not separately
reimbursable. This denial has not been substantiated so we must find in your favor. Based on this information,
we decided that Medicare rules for coverage of the CT guidance have been met. Therefore, we decided that the
Plan has to pay for computed tomography (CT) guidance for placement of radiation therapy fields (77014)
provided on April 5, 2021, through April 9, 2021.

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 waive the deductible for physician's services provided on 
March 9, 2021. 
 
You asked the Plan to waive the deductible for physician's services. You say that you never had to pay the 
outpatient deductible in the past. The Plan denied your request. The Plan says per your Evidence of Coverage, 
your deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for 
your covered medical services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 deductible which applies to covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category of What is 
your Plan Deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$250 deductible which applies to your covered medical services. This cost sharing is a contractual obligation 
that had not been met at the time physician's services was received on March 9, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for physician's services provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) therapeutic exercises (97110)
cervical collar (L0180) hands-on therapy techniques (97140) provided June 17, 2021, to July 8, 2021.

You asked the Plan to pay for the chiropractic services. You say that you really want your doctor to be
reimbursed. You have stopped therapeutic therapy. The doctor has sent you instructions for exercises to
continue at home. The Plan denied your request. The Plan says these services are not covered when rendered
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 outpatient office visit (99213) therapeutic exercises (97110) cervical collar
(L0180) hands-on therapy techniques (97140) provided June 17, 2021, to July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport provided on January 13, 2021.

You asked the Plan to waive this copayment. You say that you were weak and could not walk because you had Covid-19. You believe the copayment should be waived. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 $225 copayment for each one-way ambulance transport. Medicare is not waiving copayments for ambulance transport due to Covid-19. 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 $225 copayment charged for ambulance transport provided on January 13, 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 April 28, 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 April 28, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0673, E0675).

You asked the Plan to pay for pneumatic compression devices. You say that these items were issued for use during surgery. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of deep vein thrombosis.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema or chronic venous insufficiency with venous stasis ulcers. The record shows that these items were ordered for the prevention of deep vein thrombosis. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0673, E0675).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for each ambulance transport provided on May 12, 2021.

You asked the Plan to waive this copayment. You say that you believe this ambulance transport should be one charge one trip as it was not your fault the hospital had to transport you to and from another facility and no one told you there would be a second copayment. The Plan denied your request. The Plan says this copayment is a contractual obligation per trip, as is stated in the Plan contract.

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 $225 copayment for each one-way ambulance transport.

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 $225 copayment charged for each ambulance transport provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from May 24, 2021, to June 2, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that these services were medically 
necessary, and you were told there was no charge for the emergency services in this case. The Plan denied your 
request. The Plan says this claim was processed correctly, and the cost-share was assessed in accordance with 
the enrollee's contract. 
 
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 $465 copayment for each of the first four days of an inpatient hospital admission. There is a $0 
copayment for the fifth day and beyond. 
The enrollee has been asked to pay a $1,860 copayment for an inpatient admission that exceeded four days 
($465 x 4 = $1,860). 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 the inpatient hospital 
admission and services provided from May 24, 2021, to June 2, 2021.