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

 
We decided that the Plan does not have to waive the copayment for the joint injection procedure you had at an 
outpatient hospital facility on June 3, 2021. 
 
You asked the Plan to waive the copayment for the joint injection procedure. You say that this procedure was 
done in the pain management office, not the hospital. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that the provider billed this as an outpatient hospital.  The 
Plan says that the records confirm that you had this procedure in a fluoroscopy suite and afterward, you were 
taken to the recovery area for observation. 
 
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 $250 
copayment for outpatient surgery and services at a hospital outpatient facility.  
 You have been asked to pay a $250 copayment for the joint injection procedure. This provider bills as an 
outpatient hospital facility, not as a specialist's office. That is why the joint injection procedure falls within the 
outpatient surgery and services at a hospital outpatient facility benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the joint injection procedure you had at an outpatient hospital facility on June 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics (D6210 x2) and two retainer crowns 
(D6740 x2). 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like to appeal these 
services because you do not have any teeth in the front of your mouth, and you are unable to bite and chew 
food. The Plan denied your request. The Plan says these services are not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 two pontics (D6210 x2) and two retainer 
crowns (D6740 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22867, 22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary 
and covered by Medicare. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe 
and effective. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22867, 22869).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the Scan or brain (70450) provided on June 19, 2021.

You asked the Plan to pay for the CT Scan of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496.

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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the Scan or brain (70450) provided on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that you have a raised bed due to a knee injury 
and you have to keep your arm at a certain level while you receive dialysis. The Plan denied your request. The 
Plan says this item is a convenience item and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the over-bed table (E0274).
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 11, 2021, to May 14, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that all 
expenses would be covered because you had the coronavirus. 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 $265 
copayment for days 1-7 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 11, 2021, to May 14, 2021. Therefore, you are responsible to pay 
a $265 copayment for days 1-3 (May 11, 2021, to May 13, 2021). The total amount you owe is: $265 
(copayment) x 3 (inpatient days) = $795.  
 
You have been asked to pay the total copayment amount of $795 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 11, 2021, to May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that 
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water 
and/or phone bill payments (debit card), home assistance services (repairs). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes 
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or 
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan 
says the certification dated October 7, 2021, documented that the enrollee has none of the qualifying diagnoses, 
does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse 
health outcomes. 
 The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you 
must have one or more comorbid and medically complex chronic conditions that are life-threatening or 
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization 
or other adverse health outcomes; and must require intensive care coordination.  
 
We looked at the file and Plan?s rules. The file shows that your medical conditions are not eligible medical 
conditions for coverage under the Plan?s benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, 
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home 
assistance services (repairs).
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 
October 19, 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 for out of network care. 
 
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 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 October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and supplies.
You asked the Plan to pre-approve a Dexcom continuous glucose monitor and supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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 a Dexcom continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and supplies
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
December 16, 2020, to January 4, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford 
this copayment. 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 $290 
copayment per day for days 1-6, and a $0 copayment per day for days 7-365 for inpatient hospital care..  
 
Records show you were in the hospital for 19 days.  You were charged a $290 copayment per day for the first 6 
days in accordance with your Evidence of Coverage, for a total of $1740.  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 services provided from December 16, 
2020, to January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a folding walker/scooter purchased out of network on March 
16, 2021. 
 
You asked the Plan to pay for out of network equipment. You say that you were told this would be covered.  
The Plan denied your request. The Plan says you did not have prior authorization for out of network equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you must use Plan approved vendors for durable medial equipment. You purchased this 
equipment out of network without approval from the Plan. Therefore, we decided that the Plan does not have to 
pay for a folding walker/scooter purchased out of network on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ensure oral medical nutrition (S9433). 
 
You asked the Plan to pay for the oral medical nutrition. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says this item is not covered under 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pay for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pay for ensure oral medical nutrition (S9433).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services represented by code 87631 provided 
on May 11, 2020. 
 
You asked the Plan to pay for code 87631. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87631 
is a column II code to column I code 87633. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services represented by code 87631 provided on 
May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics provided by Hanger Prosthetics and 
Orthotics East, Inc. 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided by Hanger 
Prosthetics and Orthotics East, Inc.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance services you received on 
December 15, 2020. 
 
You asked the Plan to waive the coinsurance for the ambulance services. You say that these claims should have 
been covered by your Medicaid plan. The Plan denied your request. The Plan says you were charged this 
coinsurance correctly.  Records show that you have Medicaid, who is your secondary payer.  Medicaid pays if 
there are costs left over after Medicare pays.  You were charged this coinsurance correctly under your Medicare 
plan.  The coinsurance may be covered in full by your Medicaid plan.  The Plan states that they called the 
ambulance company and confirmed that you do not have an outstanding balance. However, the Plan states that 
this coinsurance 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 20% coinsurance for ambulance services.  
 
You have been asked to pay 20% coinsurance for the ambulance services. 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 ambulance services you received on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 30, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you fainted due to the coronavirus vaccine. 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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on March 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on March 10, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you have a heart condition, and 
the local ambulance was on another call. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cast supplies you received on May 17, 
2021, and May 19, 2021. 
 
You asked the Plan to waive the coinsurance for the cast supplies. You say that you believe the costs for the 
cast supplies should be included in your office visit copayment. The Plan denied your request. The Plan says 
you were charged this coinsurance 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 medical supplies.   
You have been asked to pay 20% coinsurance for the cast supplies. Medicare rules say that cast supplies are not 
included in the cost of an office visit.  These supplies are separately payable. That is why the cast supplies fall 
within the medical 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 cast 
supplies you received on May 17, 2021, and May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen dressing (A6021), gauze (A6219, A6220, 
A6231), specialty absorptive dressing (A6252), and the non-waterproof tape (A4450) rendered by the out-of-
network (OON) provider on June 14, 2021. 
 
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 the items were 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 items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the collagen dressing (A6021), gauze (A6219, A6220, A6231), specialty absorptive 
dressing (A6252), and the non-waterproof tape (A4450) rendered by the out-of-network (OON) provider on 
June 14, 2021.