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

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
March 28, 2022, to August 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health care. 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 $40 
copayment for outpatient mental health care. 
 
You have been asked to pay a $40 copayment for outpatient mental health care. This item/service falls within 
the outpatient mental health 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 
outpatient mental health care provided on March 28, 2022, to August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory antibiotic resistance polymerase chain 
reaction (PCR) panel (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on 
June 3, 2022. 
 
You asked the Plan to pay for the respiratory antibiotic resistance PCR panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing was not billed with a single panel 
code as required. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory antibiotic resistance PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the respiratory antibiotic resistance polymerase chain reaction (PCR) panel 
(87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the quad cane (E0105) provided on September 3, 2022. 
 
You asked the Plan to pay for the quad cane. You say that the item in this case is medically necessary. You also 
say that payment should be made. The Plan denied your request. The Plan says the records do not show proof 
of pickup or delivery for the cane and therefore is not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the quad cane provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the quad cane (E0105) provided on September 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 5, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you are requesting a reconsideration for the 
denied payment. The Plan denied your request. The Plan says self-administered drugs are not covered under 
Medicare Part B. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on January 5, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on November 3, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the enrollee was not enrolled in hospice on the date 
of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
 
 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 November 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a chest x-ray 
provided on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory services provided on 
November 10, 2021. 
 
You asked the Plan to waive the coinsurance for the laboratory services. You say that you thought this provider 
was in-network. 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 40% 
coinsurance for out-of-network diagnostic laboratory services. 
 
You have been asked to pay 40% coinsurance for the laboratory services. This item/service falls within the out-of-network diagnostic laboratory services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total you owe is $3.88 ($9.71 allowed amount x 40% coinsurance = 
$3.88). Therefore, we decided that the Plan does not have to waive the coinsurance for the laboratory services 
provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on December 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), transfer handles 
(K0108), and push handles (K0108). 
 
You asked the Plan to pre-approve a power seat elevation feature, transfer handles, and push handles. You say 
that the requested items are medically necessary. The Plan denied your request. The Plan says that the power 
seat elevation feature and transfer/push handles are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), transfer handles 
(K0108), and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an out-of-network office visit provided on 
December 14, 2022. 
 
You asked the Plan to waive the cost share for an out-of-network office visit. You say that you disagree with 
the cost share. 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. Your 
contract with the Plan says that there is a $575 deductible which applies to out-of-network 
physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network 
physician/practitioner services/ benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $575 deductible which applies to out-of-network physician/practitioner services. You 
are being asked to pay $203.20 towards your deductible. This cost sharing is a contractual obligation that had 
not been met at the time an out-of-network office visit was received on December 14, 2022. Therefore, we decided that the Plan does not have to waive the cost share for an out-of-network office visit provided on 
December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee 
will not require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 inpatient services. Our physician 
reviewer found that the enrollee has osteoarthritis of the shoulder. The Plan has approved a reverse shoulder 
arthroplasty procedure. The record does not show that the enrollees necessary hospital care will span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on October 18, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable foot insert, heel lift, and shoe depth inlay. 
 
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 items are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve a 
removable foot insert, heel lift, and shoe depth inlay.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
December 24, 2022. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that your only option 
was the emergency room. 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for the 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 the emergency room 
services provided on December 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear stress test provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that you did not exercise during 
this stress test and do not know if it was charged correctly. 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 $75 
copayment for outpatient diagnostic tests, including stress tests. 
 
You have been asked to pay a $75 copayment for the nuclear stress test. This item/service falls within the 
outpatient diagnostic tests, including stress tests 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. However, since the allowed amount is less than the standard 
copayment, you only owe $35.65. Therefore, we decided that the Plan does not have to waive the copayment 
for the nuclear stress test provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard wheelchair (K0001). 
 
You asked the Plan to pre-approve the standard wheelchair. You say that the wheelchair is necessary. The Plan 
denied your request. The Plan says the enrollee is currently renting a wheelchair since November 2022. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the standard wheelchair have not been met. The enrollee is 
confirmed to be currently renting a wheelchair since November 2022. The rules say that payment is made for 
only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. One month's rental 
for a standard manual wheelchair (K0001) is covered if a beneficiary-owned wheelchair is being repaired. 
Therefore, we decided that the Plan does not have to pre-approve the standard wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute. 
 
You asked the Plan to pre-approve a knee scooter/crutch substitute. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a knee scooter/crutch substitute is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter/crutch substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee scooter/crutch substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to uncover a metal post in jaw (code D6011) on 
tooth #20 and material to help gums grow (code D4266) on tooth #20. You asked the Plan to pre-approve surgery to uncover a metal post in jaw (code D6011) on tooth #20 and 
material to help gums grow (code D4266) on tooth #20. You say that the requested dental services are 
medically necessary. The Plan denied your request. The Plan says the requested services are non-covered 
dental services. 
 
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 
surgery to uncover a metal post in jaw (code D6011) on tooth #20 and material to help gums grow 
(code D4266) on tooth #20.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine services provided on 
November 17, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine 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 $375 
copayment for outpatient diagnostic tests/nuclear medicine services. 
 
You have been asked to pay a $375 copayment for nuclear medicine services. This item/service falls within the 
outpatient diagnostic tests/nuclear medicine services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for nuclear medicine services provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable thermometer (A9270), an oxygen probe for 
use with oximeter device, replacement (A4606), a surgical supply; miscellaneous/ pulse oximeter probe wraps 
(A4649) and a trach chamber (A4627). 
 
You asked the Plan to pre-approve supplies for a ventilator. You say that the monthly supplies were supposed 
to arrive at the home on March 14, 2023. The enrollee needs the requested supplies. The Plan denied your 
request. The Plan says the requested items are not covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested items at issue in this appeal do not serve a purpose that is primarily medical in nature. The 
records show that a disposable thermometer, the trach chambers, and an oxygen probe are not a Medicare 
covered benefit with the plan. The records also show that a pulse oximeter probe wrap is not covered because 
the Plan is paying for a reusable probe. Therefore, we decided that the Plan does not have to pre-approve a 
disposable thermometer (A9270), an oxygen probe for use with oximeter device, replacement (A4606), a 
surgical supply; miscellaneous/ pulse oximeter probe wraps (A4649) and a trach chamber (A4627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on October 31, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that you were not aware that the provider was out-of-
network. 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 a specialist visit 
provided on October 31, 2022.