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

 
We decided that the Plan does not have to pre-approve a power scooter 
 
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied 
your request. The Plan says that since you can walk safely without the use of your walker and you also have the 
walker for long distance walking then the request for a powered operated vehicle is not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 24, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers.  
 
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 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on July 6, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on 
July 6, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric scooter provided on May 28, 2020. 
 
You asked the Plan to pay for the electric scooter. You say that you needed the electric scooter. The Plan 
denied your request. The Plan says Medicare will only cover durable medical equipment (DME) if your doctors 
and DME suppliers are enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. We verified that the provider in this case, Top Mobility, does not 
accept Medicare. Based on this information, we decided that Medicare rules for coverage of the electric scooter 
have not been met. Therefore, we decided that the Plan does not have to pay for the electric scooter provided 
on May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on 
March 9, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that there is no copayment for a 
routine colonoscopy. The Plan denied your request. The Plan says the copayment applied 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 $125 
copayment for Medicare-covered services provided in an outpatient hospital. 
 
You have been asked to pay a $125 copayment for the colonoscopy with biopsy. The colonoscopy with biopsy 
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" benefit category. The records show that biopsies were performed, which is considered a 
surgical procedure. 
 
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 colonoscopy with biopsy provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nonunion or malunion repair (25400), open treatment of 
distal radial intra-articular fracture (25609), lengthening or shortening of flexor or extensor tendon (25280), 
and an extensor tendon sheath incision (25000). 
 
You asked the Plan to pay for nonunion or malunion repair, open treatment of distal radial intra-articular 
fracture, lengthening or shortening of flexor or extensor tendon, and an extensor tendon sheath incision. You 
say that these services are indicated in the operative report. 
 The Plan denied your request. The Plan says these codes are 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. 
 
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 nonunion or malunion repair, open treatment 
of distal radial intra-articular fracture, lengthening or shortening of flexor or extensor tendon, and an extensor 
tendon sheath incision. Our reviewer says that these codes are not supported. Our physician reviewer found 
these codes are not supported by the diagnosis documented.   Preoperative and postoperative diagnosis "Left 
distal radius fracture" does not specify the need for the services performed.  A more specific code to support 
services was not found in documentation submitted for review. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nonunion or malunion repair, open treatment of distal radial intra-articular 
fracture, lengthening or shortening of flexor or extensor tendon, and an extensor tendon sheath incision have 
not been met. Therefore, we decided that the Plan does not have to pay for nonunion or malunion repair 
(25400), open treatment of distal radial intra-articular fracture (25609), lengthening or shortening of flexor or 
extensor tendon (25280), and an extensor tendon sheath incision (25000).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 21, 2020. 
 
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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 the Guardant360 panel rendered on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on February 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a sleep study. You say that you would like this claim reprocessed and approved 
for payment. You say that this was medically necessary. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that these services could have been provided 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a sleep study provided on February 12, 2020 by an 
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental sedation services. 
 
You asked the Plan to pre-approve dental sedation. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The Pan covers only those dental services listed in the Evidence of Coverage. 
Dental sedation services are not covered. Therefore, we decided that the Plan does not have to pre-approve 
dental sedation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair with power 
tilt, a power seat elevation feature and power recline. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair (K0861) with power tilt, a power seat elevation 
feature (E2300) and power recline (E1007). You say that the enrollee needs a power wheelchair with tilt and 
recline function and seat elevation feature. The Plan denied your request. The Plan says the enrollee does not 
have a medical need for the multiple power options or power tilt and power recline. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 3 power wheelchair (K0861) 
with power tilt, a power seat elevation feature (E2300) and power recline (E1007). Our reviewer says that the 
power tilt and power recline feature is not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee meets criteria for the power wheelchair 
power tilt and power recline feature. Records do not indicate that the enrollee is unable to perform a functional 
weight shift or is unable to independently transfer from the wheelchair to bed for self-catheterization or the 
power seating system is needed to manage increased tone or spasticity. 
 
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 Group 3 power wheelchair (K0861) with power tilt, a power seat elevation 
feature (E2300) and power recline (E1007). have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement Group 3 power wheelchair with power tilt, a power seat elevation feature 
and power recline.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination; humerus, 
minimum of 2 views (CPT Code 73060) provided on May 13, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you do not agree with the $15 
copayment that applies to your financial responsibility as you were informed you would not have to pay the 
copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 
EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you had an x-ray on May 13, 2020. You are asked to pay a $15 copayment for the 
x-ray. Your EOC states, enrollees must pay a $15 copayment for x-rays. 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 radiologic examination; humerus, minimum of 2 views (CPT Code 73060) provided on May 
13, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided from February 12, 2020, to March 3, 2020. 
 
You asked the Plan to pay for lab tests. You say that the ordering physician determined that this testing was 
medically necessary for the diagnosis, monitoring, and/or appropriate medical management of the enrollee. The 
Plan denied your request. The Plan says that the denial of payment for these services is correct, because these 
tests were not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by a Plan contracted provider. The file does not show that the Plan provided notice 
that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the 
plan. Therefore, we decided that the Plan has to pay for laboratory testing provided from February 12, 2020, to 
March 3, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider depends on the facility to verify 
eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 
not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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. 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 medical services provided on December 12, 
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes 
(D9222), alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
(D7310) and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223 X2). 
 
You asked the Plan to pre-approve the dental services. You say that during the consultation, the surgeon 
advised that due to your high blood pressure condition and anxiety level it would be in your best interest to be 
sedated. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesia - first 15 minutes (D9222), alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310) and deep sedation/general anesthesia - each subsequent 15 
minute increment (D9223 X2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96413, 96375, J9055, J1200) provided November 
20, 2019. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the services billed. 
 
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 code 96413, 96375, J9055, & J1200 is not supported in the medical record. Specifically, 
clinical documentation was not provided to support the services billed. The plan made multiple requests for 
additional records and none were provided. Based on this information, we decided that Medicare rules for 
coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for 
injections (96413, 96375, J9055, J1200) provided November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy and chiropractic manipulative 
treatment provided on July 20, 2020. 
 
You asked the Plan to pay for chiropractic services. You say that this was necessary in order to prevent surgery. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
mechanical traction therapy is not covered when performed by a chiropractor and the chiropractic manipulative 
treatment is not shown to be active treatment. 
 
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.  
 
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 chiropractic services Our reviewer says that 
these services do not meet the Medicare criteria for coverage. Our physician reviewer found subluxation may 
be demonstrated by X-Ray or physical examination. There are no submitted imaging studies to reveal evidence 
of a subluxation. The submitted chart notes reveal tenderness, muscle spasms, fixations, restricted range of 
motion, and decreased cervical ranges of motion. These findings do not reveal evidence of subluxation. 
Therefore, this chiropractic treatment is not supported by Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pay for mechanical traction therapy and chiropractic manipulative treatment provided on July 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vocal cord scarring surgery to be provided by an out 
of network (OON) provider at the in-network benefit level. 
 
You asked the Plan to pre-approve the vocal cord scarring surgery. You say that you need this vocal cord 
scarring surgery. The Plan denied your request. The Plan says the clinical information did not support the need 
for care outside of the Plan's 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 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. In addition, we do not have enough 
information to know exactly what procedure is going to be attempted. We found no exception that would 
require the Plan to pre-approve these items/services at the in-network benefit level. Therefore, we decided that 
the Plan does not have to pre-approve the vocal cord scarring surgery to be provided by an out of network 
(OON) provider at the in-network benefit level.