Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on May 1, 2023. 
 
You asked the Plan to pay for the provided item. You say that you obtained a doctor's order for a portable 
oxygen concentrator so that you could attend your granddaughter's graduation in May. You also say that the 
plan could not provide the concentrator timely and were told to purchase the equipment and you would be 
reimbursed 80%. The Plan denied your request. The Plan says the purchased oxygen equipment is not a 
covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
concentrator purchased on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for sales tax (S9999) rendered on April 12, 2023. 
 
You asked the Plan to reimburse for sales tax (S9999). You say that you contacted the Plan to verify coverage 
and were informed of the amount of coverage and that it is a reimbursement policy. You also say that the 
provider verified this when the hearing aids were ordered. You also say you were not reimbursed the $86 tax. 
The Plan denied your request. The Plan says you do not have to pay this. The Plan also says you are not legally 
obligated to pay for this tax/surcharge. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors do not make any additional 
payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sales tax (S9999) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for sales tax (S9999) rendered on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for replacement wheelchair drive wheels (E2394) provided on July 17, 
2023. 
 
You asked the Plan to pay for replacement wheelchair drive wheels. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Medicare rules also say that submitted claims in which the unit of service exceeds the MUE value 
cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we found that the MUE for CPT code E2394 is 2. The MAI value 
for this code is 3. You billed 2 units of this code. You have not exceeded the MUE. It is the Plan's 
responsibility to support its denial with evidence. In this case, the Plan's denial is not supported, so we must 
find in your favor. Therefore, we decided that the Plan has to pay for replacement wheelchair drive wheels 
(E2394) provided on July 17, 2023.  
 
  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 pre-approve radiation therapy (0394Tx15). 
 
You asked the Plan to pre-approve radiation therapy. 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for this case, there are no compelling reasons offered for why stereotactic 
radiotherapy (SRT) would be needed over more standard approaches of radiation delivery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy (0394Tx15).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastroenterology provided on April 29, 2023. 
 
You asked the Plan to pay for the gastroenterology. You say that you are requesting reconsideration of 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 the gastroenterology 
provided on April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation provided on May 23, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulation. You say that the provider was in-network. 
 The Plan denied your request. The Plan says the provider was out-of-network, and the enrollee was referred by 
a provider who also does not work with the enrollee's plan. 
 
 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 did not pre-approve the 
chiropractic manipulation. We found no exception that would require the Plan to pay for the chiropractic 
maniupulation. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulation 
provided on May 23, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network injection procedures provided 
on August 31, 2022, to November 30, 2022. 
 
You asked the Plan to waive the coinsurance for in-network injection procedures. You say that you were under 
the impression that you would be charged the same amount you were in 2021. Youre on a fixed income and 
cannot afford this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for in-network injection procedures. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total you owe is $1572.21 ($7861.05 x 20% = $1572.21). Therefore, we 
decided that the Plan does not have to waive the coinsurance for in-network injection procedures provided on 
August 31, 2022, to November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand orthosis provided on May 22, 2023. 
 
You asked the Plan to pay for a wrist hand orthosis. You say that you are requesting reconsideration of 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 a wrist hand orthosis 
provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network benefit exception for in home visits.  
 
You asked the Plan to pre-approve an in-network benefit exception for in home visits. The Plan denied your 
request. The Plan says his is a Preferred Provider Organization member who would have to see this provider 
using their out-of-network benefits as explained in their evidence of coverage, as there are in-network 
providers in the region with no evidence that in-network specialist resources in the same geography to the 
member have been exhausted.  
 
The Plan contract says the Plan will cover services from either network or out-of-network providers, as long as 
the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, 
your share of the costs for your covered services may be higher 
 
We looked at the file and the Plans rules. The file shows that there are in-network providers in the region with 
no evidence that in-network specialist resources in the same geography to the member have been exhausted.  
Therefore, we decided that the Plan does not have to pre-approve an in-network benefit exception for in home 
visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 08, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of 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 a home visit evaluation 
provided on June 08, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 24, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you say that you feel that this 
should be a diagnostic colonoscopy with a $0 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 $250 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $250 copayment for a colonoscopy. This item/service falls within the outpatient 
hospital observation benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy 
provided on May 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the home health services provided from 
April 11, 2023, to April 27, 2023. 
 
You asked the Plan to waive the deductible for the home health services. You say that normally the home 
health does not owe anything, and the claim was processed incorrectly. 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. The 
enrollees contract with the Plan says that there is a $675 deductible which applies to until you have paid the 
deductible amount, you must pay the full cost for most of your covered services. Once you have paid your 
deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share 
for the rest of the calendar year. 
 
  The item or service you asked the Plan to waive the deductible for falls within what is your plan deductible 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 
deductible which applies to until you have paid the deductible amount, you must pay the full cost for most of 
your covered services. Once you have paid your deductible, we will begin to pay our share of the costs for 
covered medical services and you will pay your share for the rest of the calendar year. This cost sharing is a 
contractual obligation that had not been met at the time the home health services was received on April 11, 
2023, to April 27, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
home health services provided from April 11, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on June 13, 
2023. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you believe that this service 
should be covered. 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 $500 
copayment for out-of-network Medicare-covered surgery or other services provided at an ambulatory surgical 
center. 
 
You have been asked to pay a $500 copayment for a facet joint injection. This item/service falls within the out-of-network Medicare-covered surgery or other services provided at an ambulatory surgical center benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a facet joint injection provided on June 13, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), lenses (V2783), photochromatic 
tint (V2744), ultraviolet (U-V) coating (V2755), and anti-reflective coating (V2750) provided on July 5, 2023.  
You asked the Plan to pay for progressive lenses (V2781), lenses (V2783), photochromatic tint (V2744), 
ultraviolet (U-V) coating (V2755), and anti-reflective coating (V2750). You say that you purchased glasses 
along with lenses. You also say you were informed of the price, which was the deciding factor in your 
purchase. You also say that you now receive a notice that you are responsible for additional money. The Plan 
denied your request. The Plan says these services have 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 these services only once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one pair of standard lenses 
and frames every year. The record shows this benefit was exhausted on April 5, 2023. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781), lenses (V2783), 
photochromatic tint (V2744), ultraviolet (U-V) coating (V2755), and anti-reflective coating (V2750) have not 
been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), lenses 
(V2783), photochromatic tint (V2744), ultraviolet (U-V) coating (V2755), and anti-reflective coating (V2750) 
provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visits. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the services were not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve 
(64624). 
 
You asked the Plan to pre-approve RFA of the genicular nerve. 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 RFA of the genicular nerve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental procedure. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed 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 RFA of the genicular nerve have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve (64624).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on March 28, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim was not billed with the required DEX Z-code. 
 
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 states that the claim was not billed with the required DEX Z-code; 
however, they have cited the Plan internal criteria for this denial. The Plan has not provided any binding 
Medicare rules for the state of Texas where the testing was performed that state that a DEX Z-code is required 
for billing. Therefore, we decided that the Plan has to pay for the laboratory services rendered on March 28, 
2023.  
 
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 procedure code 93042 billed for March 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says code 93042 shall not be billed for cardiac rhythm monitoring in any site of service. 
 
The Plan must follow Medicare rules. The rules say that code 93042 shall not be reported for cardiac rhythm 
monitoring in any site of service.  
 
We looked at the file and Medicare rules. The file shows that code 93042 was billed for cardiac rhythm 
monitoring. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 93042 billed for March 
15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel that you do qualify for SSBCI 
services. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).