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

 
We decided that the Plan does not have to pay for an OTC COVID-19 test provided on June 26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022 and continues until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC COVID-19 test. have not been met. Therefore, we decided that the Plan does not have to pay for an OTC COVID-19 test provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for arm rests (E0973) and a seat cushion (E2608) for an approved power 
wheelchair. 
 
You asked the Plan to pay for the arm rests and seat cushion. You say that these features are medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that adjustable height armrests are covered if the 
beneficiary requires an arm height that is different from that available using nonadjustable arms and the 
beneficiary spends at least 2 hours per day in the wheelchair. 
 
The rules also state that a combination skin protection and positioning seat cushion (E2608) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.  
 
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 pay for the arm rests and seat cushion. Our reviewer 
says that the requested features are medically necessary. Our physician reviewer found the armrests are needed 
for appropriate positioning of the patients upper limbs while seated in the power wheelchair, not necessarily 
for transfers. A positioning cushion is needed to optimize pressure relief and distribute weight more effectively 
since the patient has difficulty consistently performing weight shifts while in her wheelchair. 
 
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 arm rests and seat cushion have been met. Therefore, we decided that the 
Plan has to pay for arm rests (E0973) and a seat cushion (E2608) for an approved power wheelchair.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 15, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on August 02, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this service should be fully 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 $50 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for an x-ray. This item/service falls within the in-network 
outpatient diagnostic tests and therapeutic services and 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. However, since the allowed amount is less than the 
standard copayment, you only owe $32.12. Therefore, we decided that the Plan does not have to waive the 
copayment for an x-ray provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on July 24, 2023. 
 
You asked the Plan to pay for an annual wellness visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that if youve had Part B for longer than 12 months, 
you can get an annual wellness visit to develop or update a personalized prevention plan based on your current 
health and risk factors. This is covered once every 12 months. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on July 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 22, 2023. 
 
You asked the Plan to waive the copayment for an office visit. 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 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for an 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 an office visit provided on June 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided by May 26, 2023. 
 You asked the Plan to pay for rotary wing air transport (A0431) and rotary wing air mileage (A0436). You say 
that the enrollee's condition required gastroenterology/gastrointestinal surgical and intensive care unit (ICU) 
services that were unavailable at a referring or closer facilities included the referenced facility. You also say 
that the receiving facility was the closest appropriate/tertiary care facility with the required specialty services 
and resources available to treat the enrollee's condition.  The Plan denied your request. The Plan says the 
decision to use an air ambulance in lieu of ground transportation was actually detrimental to this member's 
timely care since the closest next level of care facility is located only a 4-minute drive time away from the 
emergency department the member checked into. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for rotary wing air transport (A0431) and rotary 
wing air mileage (A0436). Our reviewer says that the member does not meet the criteria for rotary wing air 
transport (A0431) and rotary wing air mileage (A0436). Our physician reviewer found the provided records in 
this case support that the patient suffered from an illness or injury that contraindicated transportation by any 
means other than ambulance. Our physician reviewer also found that the provided documents showed that it 
would have been 26 minutes to transport the enrollee by ground and 13 minutes by air. The records do not 
support that he additional 13 minutes would have been a threat to the patient's health and safety, as the patient 
was stabilized in the emergency department. The provided records support that the transferring hospital did not 
have adequate facilities to provide the medical services needed by the member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rotary wing air transport (A0431) and rotary wing air mileage (A0436) have not 
been met. Therefore, we decided that the Plan does not have to pay for rotary wing air transport (A0431) and 
rotary wing air mileage (A0436) provided by May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided by an out-of-network 
provider from May 9, 2023, to May 11, 2023. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care was 
medically necessary. The Plan denied your request. The Plan says that the enrollees care needs could have 
been provided at a lower level of care, such as observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was admitted and underwent an upper endoscopy and colonoscopy. The 
upper endoscopy revealed chronic gastritis and the colonoscopy demonstrated a mass, which was biopsied. The 
enrollee remained hemodynamically stable. She was continued on oral iron and Eliquis was held. The enrollee 
was transferred back to the nursing facility on May 11, 2023, when she was considered medically stable with 
arranged outpatient follow-up. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided by an out-of-network provider from May 9, 2023, 
to May 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network diagnostic mammogram 
provided on August 10, 2023.  
 
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that you were told this 
needed to be done, therefore you feel you should not need to pay this amount. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. You have been asked to pay $225.79 towards that 2023 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was 
received on August 10, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an 
in-network diagnostic mammogram provided on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drugs and eye surgery on August 
01, 2023.  
 
You asked the Plan to waive the cost share for the Part B drugs and eye surgery. 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 of the cost for Part B covered Chemotherapy drugs and other Part B covered drugs. You must pay 
a $310 copay for outpatient surgery services. The provider billed in the amount of $655 and the allowed 
amount is $390.32. For the service it's, $390.32 x 20% = $78.06. For both services it's, $78.06 + $310 = 
$388.06. Therefore, results in the total cost sharing amount of $388.06. 
 
You have been asked to pay a 20% coinsurance for the Part B drugs and a $310 copayment for eye surgery. 
This item/service falls within the Medicare Part B prescription drugs and outpatient surgery, including services 
provided at hospital outpatient 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. Therefore, we decided that the Plan 
does not have to waive the cost share for the Part B drugs and eye surgery on August 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on June 28, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on June 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopic procedure provided on July 
06, 2023. 
 
You asked the Plan to waive the copayment for the endoscopic procedure. You say that the procedures were 
done in the same room and the same appointment, and should not be held responsible. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $350 copayment for the endoscopic procedure. This item/service falls 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 waive the copayment for the endoscopic procedure provided on July 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had not 
requested the ambulance services. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on July 28, 2023. 
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that they do not pay for any covered items or 
services you get from an opt out provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
services provided on July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, 83789, G0480) provided on May 4, 
2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 80307, 83789, & G0480 are not supported in the medical record. Specifically, code 
83789 is considered validity testing and is not separately payable. The lab order provided does not specify if 
the custom panel is for definitive or presumptive drug testing, therefore codes 80307, & G0480 are not 
supported. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, 83789, G0480) 
provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the paravertebral facet injection provided 
on June 13, 2023. 
 
You asked the Plan to waive the copayment for the paravertebral facet injection. You say that this service 
should be fully 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 $370 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $370 copayment for the paravertebral facet injection. This item/service falls 
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 waive the copayment for the paravertebral facet injection provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction provided on June 22, 2023. 
 You asked the Plan to pay for refraction. You say that you feel you should not have to pay for the refraction. 
The Plan denied your request. The Plan says you were informed that the service is not covered by the Plan and 
you signed a waiver. 
 
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 22, 2023.