Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 a domiciliary or rest home visit provided on 
November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (73590, 72110, 73502) provided 
on January 31, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services should be covered as you 
disagree with the charges. 
 
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 $95 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $95 copayment for the x-ray. X-rays 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 an x-ray (73590, 72110, 73502) 
provided on January 31, 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 
November 29, 2021, to November 30, 2021. 
 
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 services should be covered as 
you disagree with the charges. 
 
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 an ER visit. 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 November 29, 2021, to November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a partial maxillary denture. You say that you cannot eat properly. You say 
that you need these dentures. The Plan denied your request. The Plan says D5213 is not a covered dental 
benefit. 
 
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 a 
partial maxillary denture (D5213) to be provided by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot and cold pack therapy (97010) provided on January 
4, 2022. 
 
You asked the Plan to pay for the hot and cold pack therapy. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 97010 has a status indicator 
of B. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot and cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the hot and cold pack therapy (97010) provided on January 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0429) provided on November 7, 2021.

You asked the Plan to waive the copayment for the ambulance transportation services. 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 $250 copayment for Ambulance Services. 

You have been asked to pay a $250 copayment for ambulance transportation 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 copayment for ambulance transportation services (A0429) provided on November 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on July 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 domiciliary or rest home visit provided on July 30, 
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 an expandable controller with harness and electronic 
connection, footplate width extension bracket, and polyurethane liner for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and 
electronic connection is used to control multiple power options. The rules say that a nonadjustable skin 
protection and positioning seat cushion (E2607, E2608) is a prefabricated cushion with waterproof cover and 
footplates are coded with K0040, K0041, or K0042. 
 
We looked at the file and Medicare rules. The file shows that the expandable controller with harness and 
electronic connection is not needed to control the approved power switches. The requested cushion liner is not 
approved because the approved seat cushion and back cushion already have waterproof lining. The footplates 
are requested under code K0801. This is not the appropriate code for these services. The Plan may consider the 
request if resubmitted with correct coding. 
 
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 an expandable controller with harness and 
electronic connection, footplate width extension bracket, and polyurethane liner for a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an oxygen concentrator (E1390) provided 
on January 22, 2022. 
 
You asked the Plan to waive the copayment for the oxygen concentrator. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance should 
be covered as you disagree with the charges. 
 
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 10% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 10% coinsurance for the oxygen concentrator (allowed is $135 x 10% = $13.50). 
Oxygen concentrators fall within the Durable medical equipment (DME) and related 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 an oxygen concentrator (E1390) provided on January 22, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri 24HR 137MG extended-release capsule. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug is not of a type and/or used for a condition that is covered under 
the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gocovri 24HR 137MG 
extended-release capsule.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81479) provided on March 17, 2021. 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for code 81479 by a contract provider. The file does not show that the plan provided 
notice that code 81479 would not be covered. Under Medicare rules, this means code 81479 is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services (81479) 
provided on March 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide test strips, a non-preferred brand 
product. 
 You asked the Plan to pre-approve Accu-Chek Guide test strips. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have not tried and failed the Plan's 
preferred test strips that are covered by the Plan. The Plan says that you have no medical reason per your 
provider why you cannot use the preferred test strips covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file, the Plan's contract and Medicare rules. The services at issue are diabetic testing strips 
from a non-preferred brand. The services are available from the Plan's preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve Accu-Chek Guide test strips, a non-preferred brand product.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a nuclear stress test and 
saline infusion provided on September 2, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the stress test and saline infusion. You say that 
you were not aware of the copayment at the time of service. The Plan denied your request. The Plan says the 
correct copayment and coinsurance was applied. 
 
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 $200 
copayment for diagnostic radiology services, including nuclear scans.  Your contract with the Plan also clearly says that you must pay a 20% coinsurance if a Part B drug is used 
during a test. 
 
You have been asked to pay a $200 copayment for the stress test. You have also been asked to pay $0.14 for 
the saline infusion, which is 20% of the allowed amount ($0.72 allowed amount x 20% coinsurance = $0.14). 
The total for the visit is $200.14. The stress test and saline infusion fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
and coinsurance for a nuclear stress test and saline infusion provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal lower extremity prosthesis, axial 
rotation unit (L5984) and a lower extremity prosthesis, shank foot system with vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are a farmer, and you are active which 
causes the normal wear and tear to happen faster than usual. The foot has major wear and tear, that it has the 
potential for improper ambulation which could result in a fall resulting in injury. With you working on your 
farm there is greater risk for injury due to fall around equipment and livestock. The Plan denied your request. 
The Plan says Medicare cannot cover a replacement foot when the current foot is still under warranty. 
 
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.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of foot orthotics have not been met. Specifically, the records show that a replacement foot cannot be 
covered because the foot is still under warranty. Therefore, we decided that the Plan does not have to pre-
approve an endoskeletal lower extremity prosthesis, axial rotation unit (L5984) and a lower extremity 
prosthesis, shank foot system with vertical loading pylon (L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the services should be 
covered as you disagree with the charges. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
 
  You have been asked to pay a $40 copayment for the specialist office visit. 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 specialist office visit provided on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care (99223) provided on July 27, 
2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
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 99223 is not supported in the record. Specifically, the record indicates that the enrollee was registered outpatient on the billed date of service. This means that the claim was billed with an 
inappropriate POS code. Based on this information, we decided that Medicare rules for coverage of the 
inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital care (99223) provided on July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from August 3, 2021, to August 11, 2021.

You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that you were already charged a copayment for inpatient care. 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 $250 copayment for each hospital stay. A transfer to a different facility type is considered a new admission. 

The file shows that you were transferred from inpatient care to inpatient rehabilitation on August 3, 2021. This change in level of care is considered a new admission. Therefore, you have been asked to pay a $250 copayment for the inpatient rehabilitation care. The inpatient rehabilitation care 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 inpatient rehabilitation care provided from August 3, 2021, to August 11, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you went to the hospital on 
September 20, 2021, however you were still experiencing symptoms and had to return to the emergency room. 
The Plan denied your request. The Plan says the copayment the plan is asking you to pay is correct. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $90 copayment for each Medicare-covered emergency room visit. 
 
You have been asked to pay $90 copayment for emergency room visit. Emergency room 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 
visit provided on October 11, 2021.