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

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 15, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you had to go back to have 
this procedure done again since it wasn't done right the first time 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 $40 
copayment per office visit with your specialist provider.  
 
 
 
 
 
 You have been asked to pay $40 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 April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for arm brace provided on February 7, 2022. 
 
You asked the Plan to waive the coinsurance for arm brace. You say that this was overcharged. 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 for DME.  
 
You have been asked to pay $173 which is 20% of the allowed amount for an arm brace. The allowed amount 
is $865 (20% x $865= $173). An arm brace falls 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 coinsurance for arm brace provided on 
February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental bone growth removal (D7471). 
 
You asked the Plan to pre-approve dental bone growth removal. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not covered under your dental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided the correct Evidence of Coverage (EOC) or other 
documentation showing what is covered under your current dental benefit. Without this information, the Plans 
denial cannot be verified. Therefore, we decided that the Plan has to pre-approve dental bone growth removal 
(D7471).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 13, 2021. 
 
You asked the Plan to pay for the medical services. You say that this claim was timely filed and should be paid. 
The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on January 9, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like to appeal the denied service. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no referral 
from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
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 March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction services (code 97012) provided on 
April 25, 2022. 
 
You asked the Plan to pay for the mechanical traction services. You say that a previous claim had been paid. 
The Plan denied your request. The Plan says this is not a covered service 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 service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the mechanical 
traction services (code 97012) provided on April 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided from March 10, 
2022, to April 19, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the PT services. You say that the enrollee is entitled to all Medicare approved 
services. The Plan denied your request. The Plan says services from out-of-network providers are not covered 
unless preauthorized. 
 
  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 physical therapy (PT) services provided from 
March 10, 2022, to April 19, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on February 8, 2022 from an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you could not get hearing aids that worked 
correctly from a plan-approved provider. The Plan denied your request. The Plan says these hearing aids were 
purchased from an OON provider. The Plan also says that hearing aids are only covered when they are obtained 
through a Plan contracted provider. 
 
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 pays for 
hearing aids only when they are necessary and obtained from a contracted provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased on February 8, 2022 from an out-of-network (OON) provider.
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 due to the enrollee's complicated history, 
the daily physician needs, the need of acute hemodialysis and acute BiPap use and pulmonary care, the enrollee 
has been referred to LTAC for complex medical management with treatment from a specialized respiratory 
therapist and clinical staff with an interdisciplinary treatment team. The Plan denied your request. The Plan 
says based on Medicare guidelines and the information we have about the enrollee's condition they do not meet 
all the requirements. 
 
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 the enrollee with a significant past medical history of hypertension, hydrocephalus 
with ventriculoperitoneal shunt, right lower extremity amputation with hip disarticulation, and presence of 
colostomy and suprapubic catheter who was hospitalized on August 1, 2022 from the skilled nursing facility for 
an infected right elbow wound found to have osteomyelitis.  The enrollee underwent incision and drainage of right arm wound, bone biopsy, tendon repair with skin graft 
substitute, and wound vac placement on August 2, 2022. Per the physician post-operative note on August 16, 
2022, the enrollee underwent skin grafting to a healthy wound bed. Wound care will entail keeping dressing on 
recipient site for 7 days and may change donor site as needed. Per the infectious disease provider note on 
August 17, 2022 and physician note on August 21, 2022, the plan is to continue intravenous Zosynevery 8 
hours for a total of 23 more days (on Day 19 of 42 on August 21, 2022). Right elbow wound care 
recommendations are Ace wrap around elbow and donor site and continue wound vac. The enrollee is receiving 
appropriate care at the present setting. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a receiver (Monitor), dedicated, for use with therapeutic 
continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pay for the CGM monitor and supplies. You say that the continuous glucose monitor is a 
medical necessity and should be approved. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria as the enrollee is not insulin treated with multiple daily administrations of insulin or an insulin 
pump. 
 
 
 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM monitor and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for a receiver (Monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that the records show the medical necessity for 
these services. The Plan denied your request. The Plan says you did not timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until March 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has ear pain of uncertain 
etiology. The noted diagnosis is not an indication for which Botox is covered by the Medicare criteria. The 
services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is separately payable. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammogram provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for mammogram. You say that you have no choice in the kind of 
mammogram you get so it should be covered. The Plan denied your request. The mammogram preformed was 
billed as diagnostic. 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 $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
 
 
 
 
 
 You have been asked to pay $20 copayment for mammogram. Mammograms 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 mammogram provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 31, 2021. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 
 
 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kits purchased on February 4, 2022. 
 
You asked the Plan to pay for the COVID-19 test kits. You say that you feel you should be reimbursed for the 
test kits. The Plan denied your request. The Plan says Medicare cannot process a claim submitted by a 
beneficiary for a COVID-19 over-the-counter test. 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test kits are an OTC item. The Plan does not offer a supplemental benefit covering this service as 
this is not currently required by Medicare. However, for future purchases, these can be obtained with 
participating providers and covered by Original Medicare when using your Medicare card rather than your Plan 
card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for the COVID-19 test kits purchased on February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 
29, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that the provider coded this wrong 
it was not surgery. 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 $250 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided 
on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided on December 
26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 31 should be used 
with services for patients in a Part A covered stay and POS code 32 should be used with services for 
beneficiaries in a noncovered stay.  
 
 We looked at the file and Medicare rules. In this case, the claim was billed with POS 31. However, since the 
enrollee switched to long-term nursing care status, the correct POS code would be 32. 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 skilled nursing facility services provided on December 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that given the 
persistence of her condition, the healthcare team has prescribed the Flexitouch E0652 for daily treatments. A 
basic pump (E0651) was deemed inappropriate for her due to the presence of swelling in her trunk. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0668).