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

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, a cup holder (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you do not agree with the denial. The 
Plan denied your request. The Plan says this item does not serve a primary medical purpose. It is a convenience 
item and cannot be covered. 
 
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 a wheelchair accessory, a cup holder (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing procedures (83789) billed for date of service 
March 24, 2022. 
 
You asked the Plan to pay for validity testing. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing procedures (83789) billed for date of service March 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 17, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 care.  
 
 
  You have been asked to pay a $90 copayment for the ER visit. the ER visit falls within the Emergency 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 emergency room (ER) visit 
provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 an office visit provided on May 24, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the debridement procedures and chemical 
cauterization provided from January 10, 2022, to May 9, 2022. 
 
You asked the Plan to waive the copayments for the debridement procedures and chemical cauterization. You 
say that your out of pocket should have been $45 to see a specialty doctor at his office. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $350 
copayment for each surgical service at an outpatient hospital.  
 
 
   
You have been asked to pay the combined allowed amount of $2,896.64, which is less than the applicable 
copayment amount for each surgical service in an outpatient hospital. The debridement procedures and 
chemical cauterization fall within the Outpatient Hospital 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 copayments for the debridement procedures and chemical cauterization provided from January 10, 
2022, to May 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on November 22, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
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, the CPT Code Manual definition of code 93922 is limited bilateral noninvasive physiologic studies 
of upper or lower extremity arteries. The definition of code 95912 is nerve conduction studies; 11-12 studies. 
 
 
 
 We looked at the file and the rules. We find that CPT codes 93922 and 95921 are not supported in the medical 
record. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided on 
November 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transrectal ultrasound (TRUS) provided to the enrollee on 
April 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of code 76872 is "Ultrasound, transrectal." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the report of the anal physiology 
test is included in the records; however, there is no description of the billed transrectal ultrasound exam. In 
particular, in order to qualify for reimbursement for same a report of technique and images saved must be 
submitted which is not the case here. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a transrectal ultrasound (TRUS) provided to the enrollee on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing lab services provided on March 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that the provider was unaware of the prior authorization 
requirement. The Plan denied your request. The Plan says the claim processed correctly. The rendering 
provider is out-of-network and no prior authorization requests were made before the date of service. The Plan 
also says the enrollee does not qualify for any of the exceptions listed in the Plan contract. 
 
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 drug testing lab services provided on March 7, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (E1399) for item purchased on March 21, 2022. 
 
You asked the Plan to pay for sales tax. You say that you bought the durable medical equipment from this 
supplier because other suppliers did not have what you needed. You paid for this and you want reimbursement 
at 80 percent of the cost allowed by your benefits. The Plan denied your request. The Plan says this item is not 
covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax 
(E1399) for item purchased on March 21, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation. 
 
You asked the Plan to pre-approve endovenous ablation. 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 follows Medicare rules. Medicare rules say that Treatment of Varicose Veins of the Lower 
Extremities is covered when specific criteria are met. 
 
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 endovenous ablation. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not meet 
coverage criteria and does not support the medical necessity of the treatments in question. It is not possible to 
attribute the enrollees bilateral lower extremity ulceration to venous insufficiency without an assessment of 
lower extremity arterial perfusion. Coverage criteria require the absence of significant peripheral artery disease. 
The medical necessity and appropriateness of greater saphenous vein ablation cannot be supported without an 
assessment of arterial perfusion. Additionally, the reporting of reflux in the great saphenous vein bilaterally is 
insufficient. From the materials provided, it appears that only a single reflux measurement is described for the 
great saphenous vein, and the location of this reflux is not provided. Therefore, the criteria and corresponding 
to reflux in the saphenous vein is also not met. Lastly, coverage criteria require a 3-month period of 
conservative treatment; this criterion is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #30 (D6010), custom 
fabricated abutment on tooth #30 (D6057), and an abutment supported crown on tooth #30 (D6059). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an endosteal implant (D6010), custom fabricated 
abutment (D6057), and an abutment supported crown (D6059) are not covered by your dental benefits. 
 
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 an 
endosteal implant on tooth #30 (D6010), custom fabricated abutment on tooth #30 (D6057), and an abutment 
supported crown on tooth #30 (D6059).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a minor surgical procedure provided on 
March 29, 2022. 
 
You asked the Plan to waive the copayment for a minor surgical procedure. You say that it seems like the Plan 
didn't cover very much. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $350 
copayment for Medicare covered surgery services at a hospital outpatient facility.  
 
You are being charged $302.51 rather than the full copayment amount of $350 for a minor surgical procedure. 
A minor surgical procedure falls within the Outpatient Hospital 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 a minor surgical procedure provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on April 07, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
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 a $250 
copayment for surgery services at outpatient hospital. We cover medically-necessary services you get in the 
outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include 
but are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery. 
 
 
 
 
 You have been asked to pay a $250 copayment for outpatient services. outpatient services fall within the 
Outpatient hospital 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 outpatient 
services on April 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care (11044) provided on February 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that the services were urgent and medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
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 the wound care (11044) provided on February 14, 
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 medical services provided on November 22, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided a copy of the interim rate 
letter. The Plan denied your request. The Plan says you did not provide an interim rate letter for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage Plans may ask the billing 
provider to submit a copy of their most recent interim rate letter from the Medicare Fiscal Intermediary. While 
you did provide a copy of an interim rate letter from your Fiscal Intermediary (Novitas Solutions), the rate 
letter you provided applies only to the fiscal period of August 1, 2020, to July 31, 2021.  The services in 
dispute in this appeal occurred after this period, so an interim rate letter applicable to the date of service in 
appeal needs to be submitted.  The Plan has attempted to reach out to you multiple times to get this 
information.  The Plan has indicating that it would be willing to reconsider your request should you submit a 
correct interim rate letter to them. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for anesthesia on June 30, 2022. 
 
You asked the Plan to waive the copayment for anesthesia. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 a $345 
copayment for surgery services at ambulatory surgical center. If you are having surgery in a hospital facility, 
you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider 
writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing 
amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an 
"outpatient." 
 
 
 
 
 You have been asked to pay a $345 copayment for anesthesia. Anesthesia falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 anesthesia on June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Epogen. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has anemia of chronic kidney disease. The documentation does not support that the enrollee 
has tried and failed Retacrit or Procrit. The documentation does not support that Retacrit or Procrit would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) on tooth #19. 
 
You asked the Plan to pre-approve a crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says tooth # 19 does not show large decay requiring replacing a significant amount of 
the tooth. X-ray images show little decay, which can be restored with a conventional filling. This condition 
does not meet required clinical criteria to establish medical necessity. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation indicates that tooth #19 
does not exhibit significant coronal breakdown due to caries or fracture to warrant a crown restoration. The 
documentation provided does not meet the criteria for coverage for a crown restoration for tooth #19. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) on tooth #19.