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

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 26, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that all of the appropriate documents have been 
provided for payment. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on July 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on May 09, 
2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were told you would 
not be charged a copayment for this procedure. 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 $310 
copayment for outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $310 copayment for the outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory surgical centers 
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 $197.18. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient surgery provided on May 09, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services provided on 
January 12, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the transitional care management services. You say that the services were 
medical necessary. The Plan denied your request. The Plan says the services do not meet medical necessity for 
an out-of-network provider, such as an urgent or an emergency. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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. This service was not routine dental care. Therefore, we decided 
that the Plan does not have to pay for the transitional care management services provided on January 12, 2023, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on August 7, 2023. 
 
You asked the Plan to pay for the walker. You say that you couldn't walk without assistance and saw that the 
Plan covers walkers. The Plan denied your request. The Plan says this provider does not participate in 
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 the walker you purchased on August 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit provided on May 11, 2023. 
 
You asked the Plan to pay for the nursing facility visit. You say that this service 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 nursing facility visit provided on May 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit and the chronic pain 
management and treatment provided on June 12, 2023. 
 
You asked the Plan to waive the copayment for the office visit and the pain management and treatment. You 
say that you do not agree 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 $75 
copayment per visit for pain management treatment, and a $35 copayment per visit to a specialist. You have been asked to pay a $75 copayment for the pain management and treatment. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also 
been asked to pay a $35 copayment for the office visit. This item/service falls within the physician/practitioner 
services, including doctors office visits 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 office visit and the chronic pain management and treatment provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 4, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 14, 2023, to August 21, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you have no out-of-network benefits. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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. This service was not routine dental care. Therefore, we decided 
that the Plan does not have to pay for the office visit provided on August 14, 2023, to August 21, 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 the office visit (99212), mechanical traction therapy (97012), 
and the electric stimulation therapy (97014) provided on July 25, 2023. 
 
You asked the Plan to pay for the office visit and therapy services. You say that these services were medically 
necessary as chiropractic treatment is the only thing that provides you pain relief. The Plan denied your request. 
The Plan says these services are not covered when received by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99212), mechanical traction therapy (97012), and the 
electric stimulation therapy (97014) provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
pump. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support ongoing coverage. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation indicates that the enrollee required wound vacuum placement after developing an 
infected left popliteal bypass graft after a left popliteal endarterectomy on 7/10/2023. The most recent clinical 
documentation dated 11/29/2023 indicated that the enrollees wound had filled in with granulation tissue and 
the wound vacuum was to be discontinued with the application of another wound dressing. The enrollee no 
longer requires wound vacuum placement for wound healing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a negative pressure wound therapy pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the injection services provided on 
December 29, 2022, to August 17, 2023. 
 
You asked the Plan to reduce the copayments for the injection services. You say that you cannot afford the 
copayments. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit.  
 You have been asked to pay $175, which is less than the standard copayment for each injection service 
provided on December 29, 2022, and March 8, 2023. You have also been asked to pay a $295 copayment for 
each injection service provided on March 29, 2023, April 17, 2023, June 28, 2023, and August 17, 2023. These 
items/services fall within the outpatient surgery, including services provided at hospital outpatient facilities 
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 reduce the copayments for the injection services provided 
on December 29, 2022, to August 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit when provided by an OON 
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.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 genetic testing provided on August 4, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
and gum surgery (D4267). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 bone 
replacement graft for ridge preservation (D7953) and gum surgery (D4267).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on July 12, 2023. 
 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 Current Procedural Terminology (CPT) code 99285 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department with nausea/vomiting/diarrhea for four days. The enrollee was diagnosed with 
noninfective gastroenteritis and colitis, unspecified. The examination was unremarkable. The enrollee was alert 
and oriented without acute distress. Vitals were stable, except for high blood pressure. Imaging was negative 
for acute disease. The enrollee was treated with fluids and Zofran with benefit. The enrollee reported feeling 
better. The documentation does support an appropriate history and examination; however, it does not support 
medical decision-making of high complexity as required to justify CPT 99285.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an OON provider on July 
11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered in full. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an OON 
provider on July 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory test provided on February 
21, 2023. 
 
You asked the Plan to waive the copayment for the laboratory test. You say that it took the provider seven 
months to bill you for this service and you knew nothing about this bill. 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 $5 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $5 copayment for the laboratory test. This item/service falls within the outpatient 
diagnostic 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. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory test provided 
on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services (99310) 
provided on September 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care services. You say that the enrollee was in a nursing 
home at the time the services were rendered. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care services (99310) provided on September 19, 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 the anesthesia services billed with code 01992 for date of 
service December 28, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnoses billed makes code 01992 
covered. 
 
We looked at the file and Medicare rules. Procedure code 01992 was billed with a diagnosis M48.062 (spinal 
stenosis, lumbar region with neurogenic claudication). This diagnosis is not listed as a covered diagnosis for 
this service. This means code 01992 cannot be paid as billed. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services billed with code 01992 for date of service December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary office visit provided on August 22, 2023. 
 
You asked the Plan to pay for the pulmonary office visit. You say that the provider and facility are in-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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 pulmonary office visit provided on August 22, 2023.