Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for eight units of procedure code 11047 rendered on December 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the provider has not documented any medically necessary reason for performing extra units 
in excess of the 10 allowed. 
 
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 forwarded a valid denial. The MEU for CPT 11047 is 10 units. 
The provider has billed 8 units of this code, which is not in excess of the allowed amount of units for this code. 
There does not appear to be anything inappropriate with the claim. Therefore, we decided that the Plan has to 
pay for eight units of procedure code 11047 rendered on December 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 7, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that you were not aware that this service required 
a prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit provided on March 7, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on eye provided on 
March 29, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on eye. The Plan denied your request. The Plan says 
the primary payer will need to review the services for payment consideration before the Plan can consider the 
claim for payment consideration as secondary payer. The Plan contacted the provider and successfully relayed 
the information.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for anesthesia for procedures on eye until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on eye 
provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit provided on February 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the physician service. You say that you have been seeing this 
specialist for ten years. You say that when you signed up for this plan, you were advised this reimbursement 
would be approved. You also say that this is why you felt comfortable changing plans. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
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 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 reimburse you for the office visit provided on February 
14, 2023, 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 back brace on January 20, 2023.  
 
You asked the Plan to waive the coinsurance for back brace. You say that you want to appeal the amount being 
charged. 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 each Medicare-covered prosthetic device, including replacement or repairs of such devices, and 
related supplies. Devices (other than dental) that replace all or part of a body part or function. These include but 
are not limited to colostomy bags and supplies directly related to colostomy care, pacemakers, braces, 
prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). 
Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. Also 
includes some coverage following cataract removal or cataract surgery  see Vision Services later in this 
section for more detail. The provider billed in the amount of $975 and the allowed amount is $921.74 for the 
service. $921.74 x 20% = $184.35. Therefore, results in the total cost shairng amount of $184.35.  
 
You have been asked to pay a 20% coinsurance for back brace. This item/service falls within the prosthetic 
devices 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 back brace 
on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine 
provided from September 2, 2022, to February 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) machine. You say that there is a 
referral for this service and should be covered because it is necessary. The Plan denied your request. The Plan 
says there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-
network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a continuous positive airway pressure (CPAP) 
machine provided from September 2, 2022, to February 2, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 23, 2022, to 
March 21, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment for home health services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. Any claim with incomplete, missing, or invalid information for all of these elements may be 
returned as unprocessable.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record does not support that a 
signed plan of care for the dates of service at issue was provided. Therefore, we decided that the Plan does not 
have to pay for home health services provided from February 23, 2022, to March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and the deductible for the intraoral 
comprehensive series of radiographic images (D0210) provided on April 21, 2023. 
 
You asked the Plan to waive the coinsurance and the deductible for the dental service. You say that you are 
covered for routine cleaning and x-rays per year. 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 50% 
coinsurance for class 2 basic services after $100 deductible. The total allowed amount for the intraoral 
comprehensive series of radiographic images was $112 after the $100 deductible was charged the remaining 
balance was $12 ($112 allowed - $100 deductible). The total coinsurance amount was $6 ($12 remaining x 
50% coinsurance). Your total liability for the intraoral comprehensive series of radiographic images was $106 
($100 deductible + $6 coinsurance). 
 
You have been asked to pay a 50% coinsurance and a $100 deductible for the dental service. This item/service 
falls within the Dental 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 coinsurance and 
the deductible for the intraoral comprehensive series of radiographic images (D0210) provided on April 21, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ZooMe auto-flex folding travel scooter (K0899). 
 
You asked the Plan to pre-approve a ZooMe auto-flex folding travel scooter. You say that you were previously 
approved for a heavy-duty scooter and with your husband being 75 years old, you would not be able to lift that 
scooter into a vehicle. The Plan denied your request. The Plan says the request for a brand specific (ZooMe 
auto-flex folding travel scooter) scooter/power operated vehicle (POV) is not a covered benefit and is denied. 
The Plan also says that a comparable scooter/POV that is on the Plans list of covered DME would be sufficient 
and can be provided as an alternative to the requested brand specific item. 
 
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 pre-approve a ZooMe auto-flex folding travel scooter (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.  
 
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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain and had an epidural steroid injection on March 3, 2023, which provided 80% pain relief. The 
enrollees follow up visit on April 28, 2023, showed their pain came back. Also, the enrollees follow up on 
June 14, 2023, showed their pain their response was greater than 50 % for 6 weeks. However, the LCD criteria 
requires 50 % pain relief for three months. Therefore, the request is not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 22, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on March 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation (T2003) provided from 
November 16, 2022, to December 27, 2022, by a non-Plan approved provider. 
 
The enrollee asked the Plan to pay for the non-emergency transportation. The enrollee said that they are 
covered for transportation and should not have been denied. The Plan denied the enrollees request. The Plan 
says the denial of reimbursement is correct, as this service is only provided by the Plan's approved 
transportation provider.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trips are provided by the Plan's approved transportation 
provider. 
 
We looked at the enrollees request, the records in the case file, and the rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergency transportation (T2003) provided from November 16, 
2022, to December 27, 2022, by a non-Plan approved provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on November 10, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you went to the same audiologist that you had used 
for your old hearing aids. You say the need to make an appointment with a vendor outside of the network was 
buried in the fine print. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 received by a network 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. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 system.  
You asked the Plan to pre-approve the Dexcom G6 system. The Plan denied your request. The Plan says the 
enrollee does not meet the prior authorization rule for approval.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G6 system. Our reviewer 
says that the Dexcom G6 system is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require low blood glucose sugar or insulin use. The enrollee is not using insulin, is not having low blood 
glucose sugar levels and is not on a medication that causes low blood sugar. While the CGM might indeed help 
the enrollee adjust diet to control blood glucose sugar better, criteria for coverage for CGM are not met. We are 
also not told why a fingerstick monitoring would not suffice for the enrollee at this time. 
 
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 Dexcom G6 system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on March 16, 2023. You asked the Plan to pay for the ambulance transport service and ground mileage. You say that there were 
two transports in the same day and are requesting that the claim be reprocessed and paid. The Plan denied your 
request. The Plan says the enrollee was inpatient of a hospital therefore transportation services are not 
separately payable from the payment to the inpatient institution. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. 
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance transport service and ground mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance service, advanced life support and ground mileage provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional fillings for teeth numbers #24, 25, and 26 (D2335) 
provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 December 13, 2022, and 
December 15, 2023. Therefore, we decided that the Plan does not have to pay for additional fillings for teeth 
numbers #24, 25, and 26 (D2335) provided on December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport, ground mileage and oxygen supplies 
provided on December 12, 2022. 
 You asked the Plan to pay for the ambulance transport, ground mileage and oxygen supplies. You say that this 
transport was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from 
an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance transport, ground mileage and oxygen 
supplies provided on December 12, 2022.