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

 
We decided that the Plan does not have to pay for the lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support the billed charges. 
 
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. We find that the lab services are not supported in the records 
provided. The limited records do not indicate the testing was ordered by the enrollees treating physician, or for 
what purpose. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 January 28, 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 February 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 February 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on March 
17, 2022. 
 
You asked the Plan to pay for a pre-diagnostic test. You say that you were told the provider was in-network. 
The Plan denied your request. The Plan says that an adjunctive pre-diagnostic test (D0431) is 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, an adjunctive pre-diagnostic test is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the implant maintenance procedures when 
prostheses are removed and reinserted, including cleansing of prostheses and abutments (D6080) provided on 
April 4, 2022. 
 
You asked the Plan to reimburse you for the implant maintenance. You say that you would like to be 
reimbursed for the service. You say that you have never submitted a dental claim before. You also say that the 
provided dentist could not provide what was required. The Plan denied your request. The Plan says implant 
maintenance is not a covered service. 
 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 implant maintenance is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses 
and abutments (D6080) provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction, electrical stimulation, and manual 
manipulation of non-spinal areas provided by a chiropractor from January 3, 2022, through February 23, 2022. 
 
You asked the Plan to pay for the traction, electrical stimulation, and non-spinal manipulation. You say that 
these claims were denied, and no customer service representative was able to explain why. You wish for these 
claims to be paid. The Plan denied your request. The Plan says on review, it was decided to make payment for 
the services described by code 98940, as this is covered manual manipulation of the spine. All other billed 
services are not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction, electrical stimulation, and manual manipulation 
of non-spinal areas provided by a chiropractor from January 3, 2022, through February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were never informed that the treating 
provider was OON, or that you would have to find a new provider in 2022. The Plan denied your request. The 
Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental 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. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 12, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on April 12, 
2022. 
 
You asked the Plan to pay for a partial denture. You say that you were told this service was covered. The Plan 
denied your request. The Plan says a maxillary partial denture (D5225) is 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 pay for a 
maxillary partial denture (D5225) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
23, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was a follow up from 
surgery so it should be covered. The Plan denied your request. The Plan says the copayment 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 $15 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay $15 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors 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 copayment for specialist office visit provided on March 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on January 9, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that you cannot afford this bill so it should be 
waived. The Plan denied your request. The Plan says the copayment 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 $120 
copayment per visit for Medicare-covered emergency care.  
 
You have been asked to pay $120 copayment for ER visit. ER visits fall 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 ER visit provided on January 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on April 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim was denied after initially being 
paid. The Plan denied your request. The Plan says that the primary payer needs to review the services for 
payment consideration. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
We looked at the file and the rules. The file does not show that the Plan has met its obligation with regards to 
coordination of benefits. Specifically, the records do not show that the Plan sent the bill at issue directly to the 
primary insurer, directed the provider to send the bill to the primary insurer, or submitted a bill for 
reimbursement to the primary insurer. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan has to pay for the office visit provided on 
April 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for surgical decompression of 
forearm and/or wrist (25025) provided on February 6, 2022. 
 
You asked the Plan to pay for assistant at surgery services. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 25025 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a 
decompression of forearm and/or wrist have not been met. Therefore, we decided that the Plan does not have to 
pay for assistant at surgery services for surgical decompression of forearm and/or wrist (25025) provided on 
February 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 7, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never paid for this test in 
the past and shouldn't have to now. The Plan denied your request. The Plan says the copayment 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 $25 
copayment for Medicare-covered radiological diagnostic services, not including x-rays.  
 
You have been asked to pay $9.94 which is less than the standard $25 copayment for an ultrasound. 
Ultrasounds 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 for an ultrasound provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from 
January 6, 2022, to March 17, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that that you are being billed 
for the procedure done in the office visit and not the visit itself. You feel you shouldn't be billed for a procedure 
just because it was done in an office visit. The Plan denied your request. The Plan says the copayment 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 $30 
copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, 
home infusion professional services, and urgently needed services).  
 
 You have been asked to pay $330 ($30 x 11 visits) copayment for specialist office visits. Specialist office visits 
fall within the Physician/Practitioner Services, Including Doctors 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 copayment for specialist office visits provided from January 6, 2022, to March 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the documentation does not support that the requested portable oxygen system is medically 
reasonable or necessary. Our physician reviewer found you have symptoms of cough and shortness of breath. 
You were assessed with oxygen desaturation with exertion. Your Oxygen saturation was documented to be 
93%. The documentation does not support that the unit is medically necessary for activities of daily living 
outside of the home where a standard portable oxygen is not adequate. Therefore, you do not meet criteria for 
the requested portable oxygen concentrator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amounts for the ophthalmological services 
(92012), Ranibizumab (J2778), and Bevacizumab (J9035) provided on April 12, 2022 
 
You asked the Plan to waive the cost share amounts for the ophthalmological services, Ranibizumab, and 
Bevacizumab. You say that you are upset because of the coinsurance amount for the injections. The Plan 
denied your request. The Plan says the copayment and coinsurance amounts you are being charged are 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 $40 
copayment for each Medicare-covered eye exam and a 20% coinsurance for Medicare Part B drugs.  
 
 You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Vision Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. You have also been asked to pay a 20% coinsurance in the amount of $307.20 for the Ranibizumab 
injection. The Medicare allowed amount for Ranibizumab is $1536.00. The allowed amount of $1536.00 times 
the 20% coinsurance equals $307.20. You have also been asked to pay a 20% coinsurance in the amount of 
$13.57 for the Bevacizumab injection. The Medicare allowed amount for Bevacizumab is $67.86. The allowed 
amount of $67.86 times the 20% coinsurance equals $13.57. This means 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 cost share 
amounts for the ophthalmological services (92012), Ranibizumab (J2778), and Bevacizumab (J9035) provided 
on April 12, 2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an IV infusion provided on March 23, 
2022. 
 
You asked the Plan to waive the coinsurance for IV infusion. You say that this should be covered under Part A 
instead of Part B like in the past. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
 
 
 
 You have been asked to pay $615.31 which is 20% of the allowed amount for IV infusion. The allowed amount 
is $3,076.56 (20% x $3,076.56= $615.31).  IV infusion falls within the Medicare Part B Prescription Drugs 
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 an IV infusion provided on 
March 23, 2022.