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

 
We decided that the Plan does not have to pay the full cost for an oxygen concentrator provided on February 
11, 2022. 
 
You asked the Plan to pay the full cost for an oxygen concentrator. You say that this was needed so the enrollee 
could leave the house. The Plan denied your request. The Plan says the allowed amount has been paid for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. The rules also 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 20% coinsurance for durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator have not been met. Specifically, the record indicates that the Plan has paid 
the Medicare allowed amount for this service and is holding you responsible for a 20% coinsurance. A 
Medicare provider should accept the Medicare allowed amount as payment in full. In this case, the Plan is not 
responsible for paying the balance that remains after the Medicare allowed payment. Therefore, we decided 
that the Plan does not have to pay the full cost for an oxygen concentrator provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that you are disputing the share cost. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $35 copayment for x-ray. 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 x-ray provided on May 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on July 13, 2022. 
 
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 subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), 
anti-reflective coating (V2750) and addition to lens; tint (V2745) provided on July 12, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781), polycarbonate lenses (V2784), anti-reflective 
coating (V2750) and addition to lens; tint (V2745). You say that you have not had new glasses for two years 
and you do not know why this was denied. You also say you cannot afford this, which is why you had them use 
your old frames. The Plan denied your request. The Plan says these services exceed the maximum benefit per 
period. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard lenses in full once every 2 years. 
 
We looked at the file and the Plan's rules. The Plan rules say that standard lenses are covered in full once every 
two years. Standard lenses that are covered in full include single vision, lined bifocal, lined trifocal, lenticular, 
and standard progressive lenses. The record shows that lenses were purchased on March 26, 2021. Based on 
this information, we decided that the Plan's rules for coverage of progressive lenses (V2781), polycarbonate 
lenses (V2784), anti-reflective coating (V2750) and addition to lens; tint (V2745) have not been met. 
Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses 
(V2784), anti-reflective coating (V2750) and addition to lens; tint (V2745) provided on July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging (78452), cardiovascular 
stress test (93015), and technetium tc-99m sestamibi (A9500) provided on May 11, 2022, by a Medicare opt-
out provider. 
 
You asked the Plan to pay for the myocardial perfusion imaging, cardiovascular stress test, and technetium tc-
99m sestamibi. You say that previous services rendered by this same provider have been reimbursed at out-of-
network rates. You also say that you do not believe this treating provider's Medicare status changed recently. 
The Plan denied your request. The Plan says these services were rendered by a provider who does not accept 
Medicare assignment. The Plan also says that the treating provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
myocardial perfusion imaging (78452), cardiovascular stress test (93015), and technetium tc-99m sestamibi 
(A9500) provided on May 11, 2022, by a Medicare opt-out 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 of service 
July 19, 2022. 
 
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 of service July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has been on a CPAP/BIPAP on and 
off since 2002 with no success. You would like a further review of the medical records to see if this decision 
can be overturned. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in AVAPS mode without Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found A home ventilator is not medically necessary.  This enrollee was recently hospitalized with a COPD exacerbation, and improved on treatment, which included 
BiPAP. There is a diagnosis of obstructive sleep apnea, but it is unclear whether it was being treated. Arterial 
blood gases (ABG) in the hospital were consistent with acute on chronic CO2 retention, although there is no 
ABG done while stable to confirm chronic CO2 retention. This enrollee may benefit from BiPAP with AVAPS 
during sleep, which has not been tried and failed as an outpatient. But Medicare does not cover a home 
ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility services provided on July 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility services. 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 nursing facility services provided on July 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 17, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware that treatment with no transportation was not covered. The Plan denied your request. The Plan says 
this service was denied correctly. 
 
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 December 17, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 28, 2021, 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 October 28, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings were ordered by your 
doctor for varicose veins, bilateral enlarged leg veins, bilateral swelling, restless legs bilaterally, discomfort 
bilaterally and bilateral leg pain, but no bilateral ulceration. The Plan denied your request. The Plan says you 
do not have any qualifying wounds or ulcers. The requested item is noncovered under the surgical dressing 
benefit as it does not meet the statutory definition of a dressing. You do not have the item as a benefit per your 
EOC. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 
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 
A6533.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameter provided on 
May 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for remote monitoring of physiologic parameter. 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 it was determined these services can be received in-network. 
 
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 remote monitoring of physiologic parameter 
provided on May 20, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 29, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree 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 $440 
copayment for ambulance services.  
 
You have been asked to pay a $440 copayment for ambulance services. This item/service falls 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 July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says authorization was not obtained prior to services being 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 office visit provided on July 29, 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 office visit provided on October 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says under certain circumstances, the enrollee may obtain services from out-of-network 
providers. Newly eligible enrollees who are undergoing an existing course of treatment under the care of an 
out-of-network provider at the time of eligibility may continue to obtain services from that provider for up to 
forty-five (45) days or until treatment can be transitioned to an in-network provider. Out-of-network providers 
with enrollees under a current treatment plan have up to forty-five (45) days to notify the health plan and 
request authorization of services, as appropriate according to the plan benefits. Once the health plan is notified 
that the member is under the care of an out-of-network provider, the provider must submit a request for 
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 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 office visit provided on October 28, 2021, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the share cost for office visit and ultrasound provided on May 
23, 2022. 
 
You asked the Plan to waive the share cost for office visit and ultrasound. You say that you are disputing the 
share cost. 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 $86.79 
deductible for physician/practitioner services, including doctor's office visits. You also must pay $305.49 
deductible for outpatient diagnostic tests and therapeutic services and supplies. The total cost for office visit 
and ultrasound is $392.28. 
 You have been asked to pay $392.28 deductible for office visit and ultrasound. These items/services fall within 
the outpatient diagnostic tests and therapeutic services and supplies and physician/practitioner services, 
including doctor's office visits benefit categories. 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 share cost for 
office visit and ultrasound provided on May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast augmentation. 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee's ongoing surgical issues and pending 
reconstructive surgery have had significant impact on mental health and self-esteem. The Plan denied your 
request. The Plan says this is not cosmetic and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
requested surgery is not medically reasonable or necessary. Our reviewer found the record indicates that the 
enrollee desires breast augmentation for cosmetic and mental health reasons. The record does not indicate that 
the enrollee requires prompt repair of accidental injury or to improve the functioning of a malformed body 
member. The requested procedure is a cosmetic procedure. The elements of the coverage criteria are not 
satisfied. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast augmentation.