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

 
We decided that the Plan does not have to pay for the Hearing aid, digital, binaural, BTE (V5261) purchased 
August 25, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you went to the in-network provider for testing, 
needed hearing aids and believed they had received the approval for the hearing aids. You paid your deductible 
and then was billed the whole amount for the hearing aids. The Plan denied your request. The Plan says there is 
no coverage for hearing aids or related services when received from an out of network 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 the hearing aids are covered when purchased from the designated in-network vendor.  
 
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 aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
Hearing aid, digital, binaural, BTE (V5261) purchased August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that the enrollee was seen for a 
wellness visit and should not have a copayment. The Plan denied your request. The Plan says the enrollee has 
been charged the correct cost sharing amount. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment for annual wellness visits. If you receive services that address a medical condition 
during the same office visit, additional cost sharing may apply. 
 
The enrollees contract with the Plan also clearly says that enrollees must pay a $10 copayment for each visit 
with your PCP. 
 
The records show that additional services were provided/discussed during the wellness visit. Therefore, the 
enrollee has been asked to pay a $10 copayment for the PCP office visit. The PCP office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a primary care physician (PCP) office visit provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473x2), deep 
sedation/general anesthesia, first 15 minutes (D9222) and deep sedation/general anesthesia, each 15-minute 
increment (D9223x3). 
 
You asked the Plan to pre-approve removal of torus mandibularis, deep sedation/general anesthesia, first 15 
minutes and deep sedation/general anesthesia, each 15-minute increment. You say that you were supposed to 
have a total extraction performed but your authorization was denied. You also say you are supposed to have all 
teeth removed, torus removal and sedation. You are requesting reconsideration for the denial of non-covered 
benefits. The Plan denied your request. The Plan says the requested services are not covered benefits under 
your dental 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 pre-approve 
removal of torus mandibularis (D7473x2), deep sedation/general anesthesia, first 15 minutes (D9222) and deep 
sedation/general anesthesia, each 15-minute increment (D9223x3).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 27, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the copayment amount charged 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 $160 
copayment for Medicare-covered ultrasounds performed in a physician's office or at a free-standing facility 
(such as a radiology center or medical clinic).  
 
 
 You have been asked to pay a $132.12 copayment for your ultrasound, which is less than EOC documented 
$160 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 the 
ultrasound provided on May 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies (A4222) provided from August 27, 
2021, to August 29, 2021. 
 
You asked the Plan to pay for the infusion services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 August 26, 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 the infusion supplies 
(A4222) provided from August 27, 2021, to August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) provided by an out-of-
network provider on September 13, 2021. 
 
You asked the Plan to pay for a prefabricated abutment. You say that when you called you were told that this 
would be covered. The Plan denied your request. The Plan says D6056 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
prefabricated abutment (D6056) provided by an out-of-network provider on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 acupuncture treatments. 
 
You asked the Plan to pre-approve 8 acupuncture treatments. 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 acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 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 8 acupuncture treatments. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the authorization of 
a total of 20 visits under authorization 20211201-000146 for the dates of service November 29, 2021 to April 
3, 2022, your benefit level has been reached per Medicare NCD guideline. The review has determined that the 
enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 acupuncture treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 acupuncture treatments.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says when specimen 
validity testing is conducted as part of drug testing, it cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested validity testing is not separately payable in this case. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the prophylaxis (D1110) and bitewing x-ray (D0274) provided on 
October 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentist has recommended more than 2 
prophylaxis per year due to your clinical situation. You say that you still only receive 2 exams per benefit 
period. You also say that you do not understand why the services are not covered. The Plan denied your 
request. The Plan says that the maximum benefit of $800 per year has been exceeded. 
 
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. Specifically, the file does not include documentation to support the Plan's denial. 
There is no documentation that supports that the enrollee has exhausted the benefit for prophylaxis. 
Additionally, there is no documentation to support that the maximum allowance has been met. Therefore, we 
decided that the Plan has to pay for the prophylaxis (D1110) and bitewing x-ray (D0274) provided on October 
22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in 
Intelligent Volume Assured Pressure Support (iVAPS) mode that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient has COPD, and was recently 
hospitalized with pneumonia, COPD exacerbation, and other co-morbidities. An arterial blood gas test (ABG) 
while acutely ill showed mild CO2 retention, but there is no documentation of chronic CO2 retention with an 
ABG while stable. Medicare does not cover a ventilator when used as BiPAP, and certain BiPAP devices can 
provide the Average volume-assured pressure support (AVAPS) mode of support, at less cost to the patient. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable 
ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laser vaporization of the prostate. 
 
You asked the Plan to pre-approve the laser vaporization of the prostate. You say that this procedure is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
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 pre-approve the laser vaporization of the prostate. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is an 80-year-old with benign prostatic hyperplasia and 
urethral stricture disease with an American Urological Association (AUA) score of 4 and prostate volume of 80 
cc. Cystoscopy revealed a bulbar stricture and scope could not be advanced beyond the stricture. Current 
treatment is with tamsulosin and finasteride. In this case, the medical records do not indicate that the laser 
vaporization of prostate is medically necessary. The enrollee has minimal symptoms (AUA score of 4) and also 
has an untreated urethral stricture. 
 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 laser vaporization of the prostate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the laser vaporization of the prostate.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide services provided on August 17, 2021 
to September 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health aide services. You say that you are requesting reconsideration of 
payment for the home health services provided to the enrollee. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health aide services provided on August 
17, 2021 to September 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) supplies provided on October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that the equipment did not fit 
properly and you felt rushed when you picked it up. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME), including CPAP supplies. 
 
 
 Item Allowed Amount 20% Coinsurance 
Headgear (A7035) $19.30 $3.86 
CPAP Machine (E0601) $77.14 $15.43 
Tubing (A7037) $16.13 $3.23 
Humidifier (E0562) $150.87 $30.17 
Face Mask (A7030) $96.16 $19.23 
Total:  $71.92 
 
You have been asked to pay $71.92, which is 20% of the allowed amount for the CPAP supplies. The CPAP 
supplies fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for continuous positive airway pressure (CPAP) supplies provided on 
October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical 
spine fusion and was discharged home. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 6, 2021. 
 
You asked the Plan to pay for the lab 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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
 We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on April 6, 2021.