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

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 11, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not advised that the 
administered Vitamin B shot would not be covered by your Plan. The Plan denied your request. The Plan says 
that self-administered drugs do not fall under Medicare Part B coverage. 
 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 the self-administered drugs 
provided on July 11, 2023.  
 
Benefits for the 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
June 26, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you should not be 
responsible to pay your copayment because an MRI was not performed. 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 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 June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92012) and scanning 
computerized ophthalmic diagnostic imaging (92134) provided on August 08, 2023. 
 
You asked the Plan to pay for a medical eye examination (92012) and scanning computerized ophthalmic 
diagnostic imaging (92134). You say that you state that this provider is listed as in-network on the Plans 
website. 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 medical eye 
examination (92012) and scanning computerized ophthalmic diagnostic imaging (92134) provided on August 
08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You may benefit from bilevel positive airway pressure (BiPAP) with volume assurance. The 
medical records do not show this has been tried and failed as an outpatient. Medicare does not cover a home 
ventilator when used with settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on June 22, 
2023, to June 26, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. The Plan denied your request. The Plan 
says that the chiropractic manipulative treatment is available in network. 
 
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 chiropractic manipulative treatment provided 
on June 22, 2023, to June 26, 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 remote monitoring and chronic care management provided 
on May 21, 2023, to May 31, 2023. 
 
You asked the Plan to pay for remote monitoring and chronic care management. You say that you are 
requesting reconsideration for the denied claim. 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 remote monitoring and 
chronic care management provided on May 21, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on March 23, 
2023. 
 
You asked the Plan to pay for evaluation and management services. You say that you are requesting 
reconsideration for the denied claim. 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 evaluation and 
management services provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management of an established patient 
provided on August 22, 2023. 
 
You asked the Plan to pay for evaluation and management of an established patient. You say that you are 
requesting reconsideration for the denied claim. 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 evaluation and 
management of an established patient provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on September 13, 2022, to 
September 23, 2022. 
 
You asked the Plan to pay for office services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the provider does not bill the primary Plan first; Medicare 
may not pay conditionally on the liability. 
 
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 providers 
must bill the primary Plan before billing Medicare, and the primary payer payment information that appears on 
all primary payer remittance advices must appear on the claim submitted to Medicare. As the secondary 
insurer, the Plan cannot be held responsible for office services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for office services provided on 
September 13, 2022, to September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction provided on June 16, 2023. 
 
You asked the Plan to pay for refraction. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says refraction is non-covered and not payable. The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for refraction provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), sphere lenses (V2100) and 
polarization (V2762) provided on August 1, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), sphere lenses (V2100) and polarization (V2762). You 
say that you are inquiring if there is a deductible for services rendered. The Plan denied your request. The Plan 
says this benefit has been exhausted. 
 
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 a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses (1 per 
year). 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses (1 per year). The Plan rules also say you are responsible for any 
amount over the $200 retail price. The record shows that this benefit was exhausted with this date of service. 
Specifically, there is a $200 benefit that is applied to the retail price. The record also shows that there is no 
deductible applied here. Based on this information, we decided that the Plan's rules for coverage of deluxe 
frames (V2025), sphere lenses (V2100) and polarization (V2762) have not been met. Therefore, we decided 
that the Plan does not have to pay for deluxe frames (V2025), sphere lenses (V2100) and polarization (V2762) 
provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the porcelain/ceramic crown (D2740) 
and the core buildup, including any pins when required (D2950) provided on December 30, 2022. 
 
You asked the Plan to issue additional payment for the dental items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the dental items provided 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 items provided was exhausted on date of service December 30, 2022.  
  
 
 
 
Specifically, the Plans contract states that the annual maximum dental benefit is $1,500. The record shows that 
the Plan issued payments for the total amount of $1,500 for dental services provided in the 2022 calendar year. 
Therefore, you have exhausted the allowable benefit for the dental items provided in this case. Therefore, we 
decided that the Plan does not have to issue additional payment for the porcelain/ceramic crown (D2740) and 
the core buildup, including any pins when required (D2950) provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transthoracic echocardiography provided on August 29, 
2022. 
 
You asked the Plan to pay for transthoracic echocardiography. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the provider does not bill the primary Plan 
first; Medicare may not pay conditionally on the liability. 
 
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 the Plan has 
providers must bill the primary Plan before billing Medicare, and the primary payer payment information that 
appears on all primary payer remittance advices must appear on the claim submitted to Medicare. As the 
secondary insurer, the Plan cannot be held responsible for transthoracic echocardiography until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for 
transthoracic echocardiography provided on August 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on August 2, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425). You say that the submitted records clearly indicate the medical necessity of this 
service. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance service, basic life support, non-emergency transport (A0428) and ground mileage 
(A0425) have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425). Therefore, we decided that the Plan does not have to pay for 
ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided 
on August 2, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system (33289). 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 a CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system (33289).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on June 02, 
2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this 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 $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. This item/service falls within the outpatient 
rehabilitation 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. You have been asked to pay a $20 copayment for physical therapy services on June 2, 
2023. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided 
on June 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gradient compression stockings and ankle foot orthosis 
(L1940, A6534, A6531) provided on August 29, 2023. 
 
You asked the Plan to pay for the gradient compression stockings and ankle foot orthosis. You say that the 
items should be covered as you disagree with the denial. The Plan denied your request. The Plan says the items 
denied correctly as the rendering provider is not enrolled with Medicare. 
 
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 gradient compression stockings and 
ankle foot orthosis (L1940, A6534, A6531) provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit provided on June 01, 2023. 
 
You asked the Plan to pay for a hospital visit. You say that this was medically necessary and should be 
covered. 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 hospital visit provided 
on June 01, 2023.