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

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism (87798) provided on April 
27, 2022. 
 
You asked the Plan to pay for the polymerase chain reaction (PCR) testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says PCR testing is not indicated as the following 
are appropriate means to verify fungal infection. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the polymerase chain reaction (PCR) testing. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the medical documentation does not support that this enrollee has 
had their toenail specimen evaluated with potassium hydroxide (KOH) to look for fungal elements, nor has the 
toenail specimen undergone fungal culture. These two laboratory tests are standard of care for the evaluation of 
onychomycosis. They have been proven to be very efficient in demonstrating fungus within a toenail. They are 
also inexpensive, certainly as compared to PCR testing. It appears that the PCR testing exceeded this enrollees 
medical needs and is currently not standard of 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 polymerase chain reaction (PCR) testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique (87481) and infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown tooth #13 
(D2954) provided on October 12, 2022. 
 
You asked the Plan to pay for the prefabricated post and core in addition to crown tooth #13 (D2954). The Plan 
denied your request. The Plan says this service is not covered under the benefit package. 
 
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 
prefabricated post and core in addition to crown tooth #13 (D2954) provided on October 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you are disputing the appeal for A0998 
ambulance no transport. You also say that you didn't actually go to the hospital so you should not have to pay. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Power wheelchair, group 2 heavy-duty, captain's chair, 
patient weight capacity 301 to 450 pounds (K0825), provided on November 27, 2021. 
 
You asked the Plan to pay for the heavy duty wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the information available shows the member will be using the power 
wheelchair outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 
pounds (K0825), provided on November 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the negative pressure wound therapy services coded 97605 
provided on April 27, 2022. 
 
You asked the Plan to pay for the negative pressure wound therapy services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are 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 code 97605 is negative pressure wound therapy (eg, vacuum 
assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), 
wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or 
equal to 50 square centimeters. 
 We find that CPT code 97605 is not supported in the medical record. Specifically, the documentation shows 
that the wound was dressed with wound vac dressing. There was no documentation to support wound 
assessment and enrollee or caregiver instruction related to ongoing care per session. This code is not the 
appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare 
rules for coverage of the negative pressure wound therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for the negative pressure wound therapy services coded 97605 provided on 
April 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
August 16, 2022 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for emergency room services. This item/service 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 emergency room services 
provided on August 16, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness 
(E2313) and an expandable controller (E2377). 
 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee is unable to perform 
functional weight shift by any method throughout the day despite having strength of 4-5/5. She is at high-risk 
skin breakdown & requires tilt. Specialty cushion alone w/o tilt will not meet needs as she is unable to weight 
shift as noted. Power tilt alone will not meet pressure relief needs due to her abnormal positioning. The Plan 
denied your request. The Plan says a seat elevator does not serve a primary medical purpose and is non-
covered. Although there are three requested power options (tilt, recline and elevating leg rests), there is not a 
medical need to control the requested accessories through the joystick. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation and is medically reasonable and necessary. 
 
The seat elevator does not serve a primary medical purpose and is statutorily not covered. The records show 
that the enrollees upper limb strength and function are adequate for the enrollee to be able to control the power 
options using their own switches which are included in the allowance of these power options. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness 
(E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cataract procedure provided on August 
22, 2022. 
 
You asked the Plan to waive the coinsurance for a cataract procedure. You say that you already paid your 
copay for this procedure, you should not owe anything else. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $388.40, 
resulting in a coinsurance amount of $77.68 ($388.40 x 20% = $77.68). 
 
You have been asked to pay a $77.68 coinsurance for a cataract procedure. This item/service 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 a 
cataract procedure provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781) and vision item or service 
(V2799) provided on August 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the progressive lens and vision item or service. You say that you have used this 
same provider in the past for glasses, and do not understand what the problem is. The Plan denied your request. 
The Plan says the treating provider is OON with your plan, and there is no coverage when services are rendered 
by a non-participating provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the progressive lens and vision item or service have not been met. 
Therefore, we decided that the Plan does not have to pay for the progressive lens (V2781) and vision item or 
service (V2799) provided on August 23, 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 radiographic x-ray provided on September 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a radiographic x-ray provided on September 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on September 14, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay $45 copayment for office visit. This item/service 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 copayment for office visit provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a manual wheelchair with accessories 
provided on August 22, 2022. 
 
You asked the Plan to waive the coinsurance for a manual wheelchair with accessories. You say that you were 
not told that this would cost so much, and the accessories are unnecessary. We are on a limited income and 
need assistance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this drug or 
item is $3063.71, resulting in a coinsurance amount of $612.74 ($3063.71 x 20% = $612.74). 
 
You have been asked to pay a $612.74 coinsurance for a manual wheelchair with accessories. This item/service 
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 a manual wheelchair with accessories 
provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on July 31, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that the 
incorrect test was preformed, and this MRI was a repeat. You feel you should not have to pay a second copay. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $135 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $135 copayment for a magnetic resonance imaging (MRI) scan. This 
item/service 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 a magnetic resonance imaging (MRI) scan provided on July 
31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on July 
27, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told by the provider that the x-ray 
would be covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the panoramic radiographic image is not covered by the Plan. 
 
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 the 
panoramic radiographic image (D0330) provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies (99499), purchased on January 24, 
2022, through June 10, 2022. 
 
You asked the Plan to pay for the medical supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the medical supplies (99499), purchased 
on January 24, 2022, through June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for F5 (coagulation factor V) (eg, hereditary hypercoagulability) 
gene analysis, Leiden variant (81241). 
 
You asked the Plan to pay for F5 gene analysis. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the Factor V Leiden variant in 
the F5 gene is noncovered. 
 
We looked at the file and Medicare rules. This testing is not covered under Medicare. Therefore, we decided 
that the Plan does not have to pay for F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene 
analysis, Leiden variant (81241).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on June 
27, 2022, to June 29, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service 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 emergency room services 
provided on June 27, 2022, to June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on June 2, 
2022, to June 9, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of these drugs total $3,900, resulting 
in a total coinsurance amount of $780.  
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. This item/service 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 
Medicare Part B drugs provided on June 2, 2022, to June 9, 2022.