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

 
We decided that the Plan does not have to pay for replacement hearing aid batteries purchased from April 20, 
2021, to October 22, 2021. 
 
You asked the Plan to pay for replacement hearing aid batteries. You say that you would like these claims 
reprocessed and approved for reimbursement. The Plan denied your request. The Plan says hearing aid batteries 
are not covered per the Plan's contract. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract 
specifies that replacement items such as hearing aid batteries are not covered. Based on this information, we 
decided that the Plan's rules for coverage of replacement hearing aid batteries have not been met. Therefore, we 
decided that the Plan does not have to pay for replacement hearing aid batteries purchased from April 20, 2021, 
to October 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 20, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the 
services were not authorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility services provided to the enrollee on 
October 28, 2021. 
 
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 provider is not participating. 
 
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 assisted living facility services provided to the 
enrollee on October 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 10, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the Plan 
has insufficient documentation to corroborate the services so the Plan cannot confirm Medicare coverage has 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physical therapy services provided on 
September 10, 2021 have been met. Therefore, we decided that the Plan does not have to pay for physical 
therapy services provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services provided to the enrollee on October 5, 
2019. 
 
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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 83020: 
 
Alcohols 
 
CPT 93005: 
 
Cardiopulmonary resuscitation (eg, in cardiac arrest)  
CPT 92950: 
 
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 
 
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 in terms of CPT 83020, the 
medical records do not include documentaiton of Hemoglobin fractionation and quantitation; electrophorsis, 
and therefore cannot be verified. In terms of CPT 93005, the documentation supports cardiopulmonary 
resuscitation (CPR), however, this procedure should be reported with the appropriate modifier, as a separate 
service. In terms of CPT 92950, the documentation does not support this procedure as a separate procedure 
from CPT 92950, as this procedure would be performed in addition to CPR. 
 
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 the various services provided to the enrollee on October 5, 2019.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump, flex-walk system or equal, and 
multiaxial ankle with swing phase active dorsiflexion feature. 
 
You asked the Plan to pre-approve a vacuum pump, flex-walk system or equal, and multiaxial ankle with swing 
phase active dorsiflexion feature. 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 a determination of the type of foot for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 vacuum pump, flex-walk system or 
equal, and multiaxial ankle with swing phase active dorsiflexion feature. Our reviewer says that the services are 
not medically necessary. Our physician reviewer found per documentation; the physician note indicates a 
recommendations for an elevated vacuum system. The literature reviewed indicates that further research is 
needed with clinical trials that recruit larger sample sizes and report long-term outcome data for the requested 
vacuum suspension system. 
 
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 vacuum pump, flex-walk system or equal, and multiaxial ankle with swing 
phase active dorsiflexion feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve a vacuum pump, flex-walk system or equal, and multiaxial ankle with swing phase active dorsiflexion 
feature.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Boostrix injection. 
 
You asked the Plan to pre-approve a Boostrix injection. The Plan denied your request. The Plan says as the 
vaccine is not to be administered due to an injury or exposure to a condition, it is not a covered benefit under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Boostrix injection. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Boostrix 
injection. Therefore, we decided that the Plan does not have to pre-approve a Boostrix injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on February 9, 
2022. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that the services should be covered 
as you disagree with the charges, and it was a routine service. 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 $15 
copayment for Podiatry services.  
 
 
  You have been asked to pay a $15 copayment for the podiatry visit. Based on your contract with the plan, if 
additional services are performed during your visit, it will no longer be considered a routine 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 podiatry visit provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging (92134) 
provided on January 11, 2022, and February 8, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging. 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 an $85 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $151.28 copayment for two ophthalmic imaging service visits which is less than 
the standard $85 copayment each. Ophthalmic diagnostic imaging 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 
ophthalmic diagnostic imaging (92134) provided on January 11, 2022, and February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate dressing (A6196) and the foam dressing (A6212) 
rendered by the out-of-network (OON) provider on December 28, 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 alginate dressing (A6196) and the foam dressing (A6212) rendered by the out-of-
network (OON) provider on December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (72110) provided on November 
29, 2021. 
 
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 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 $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 (72110) provided on 
November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient office visit provided on 
December 2, 2021. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that when you made your 
appointment there was no mention of any charge. The Plan denied your request. The Plan says the coinsurance 
was 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 50% 
coinsurance for out-of-network provider office visits. The allowed amount was $75, resulting in a coinsurance 
amount of $37.50. 
 
You have been asked to pay a total of $37.50 for the office visit. Outpatient office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 the outpatient office visit provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652), a segmental pneumatic appliance for use with a pneumatic compressor, 
trunk (E0656), and segmental pneumatic appliances for use with a pneumatic compressor, full leg  
(E0667 x 2) to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider is not a network provider with the Plan. The Plan has network providers available who 
can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve 
these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, 
segmental home model with calibrated gradient pressure (E0652), a segmental pneumatic appliance for use 
with a pneumatic compressor, trunk (E0656), and segmental pneumatic appliances for use with a pneumatic 
compressor, full leg (E0667 x 2) to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 87801) rendered by 
the out-of-network (OON) provider on February 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (87481, 87798, 87801) rendered by the out-of-network 
(OON) provider on February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long-term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on 
December 10, 2021 and December 28, 2021. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you thought the charges 
would be the same as the previous visit to a specialist, which is $30. Your complaint about the two charges is 
not a valid appeal for medical coverage. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $150 
copayment for Medicare-covered surgery at an outpatient hospital facility.  
  
You have been asked to pay a $150 copayment for each facet joint injection. The total amount you owe is $300 
($150/injection x 2 injections = $300). The facet joint injections fall within Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The 
records show the injections were billed by the hospital. 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 facet joint injection provided on December 10, 2021 and December 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound received on November 4, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that when dealing with breast cancer 
you'd think it would be covered. The Plan denied your request. The Plan says the copayment that was applied 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 $125 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic) for ultrasounds.  
 
 
  You have been asked to pay a total of $110.78 for the ultrasound. The allowable amount was $110.78 which is 
less than the standard $125 copayment, therefore you will not be charged more than the allowable amount.  
Ultrasound falls within the Other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays 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 ultrasound received on 
November 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77021, 77022, 00902) provided February 
8, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider has opted out of Medicare and is not eligible for payment. 
 
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 radiology 
services (77021, 77022, 00902) provided February 8, 2021.