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

 
We decided that the Plan does not have to waive the copayment for lesion excision and wound repair (11602, 
12032) performed on August 19, 2020. 
 
You asked the Plan to waive the copayment for lesion excision and wound repair. You say that you have had 
these services in the past and were never charged. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
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 for outpatient procedures and services, including outpatient surgery performed in an outpatient 
hospital or ambulatory surgical center.  
 
You have been asked to pay a $75 copayment for lesion excision and wound repair. Lesion excision and wound 
repair fall within the "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 copayment for lesion 
excision and wound repair (11602, 12032) performed on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on August 4, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you wouldn't have had the procedure if 
you knew it cost that much. You say that this should be covered in full. 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 20% 
coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $75 copayment for the MRI. The MRI falls within the "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. Therefore, we decided that the Plan does not have to waive the copayment 
for the MRI provided on August 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 1, 2020 to February 26, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an 
 
 
appropriate Q code is required to process and pay home health claims. This claim was not submitted with an 
appropriate Q code. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from February 1, 2020 to February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the raised toilet seat, alert system, and sales tax. 
 
You asked the Plan to pay for these services. You say that the items help the enrollee get up and prevent falls. 
The Plan denied your request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the raised toilet seat, alert system, and sales tax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1999) received on June 30, 2020. 
 
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 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services (D1999) received on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, without spectral or color 
Doppler echocardiography (CPT Code 93307). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says there is no information that you have a heart murmur, chest pain, or any symptoms 
suggestive of a heart problem. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no information that you have a heart murmur, chest pain, or any symptoms suggestive 
of a heart problem. There is no specific clinical rationale for the requested echocardiogram. The review has 
determined that the requested  echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography 
(CPT Code 93307) is not medically necessary or reasonable. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-
mode recording, when performed, complete, without spectral or color Doppler echocardiography (CPT Code 
93307).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for ambulance services provided on May 
18, 2020. 
 
You asked the Plan to reimburse the copayment for ambulance services. You say that you had to be transported 
and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $275 
copayment for ambulance services.  
 
You have been asked to pay the allowed amount of $228.17, which is less than the $275 copayment for 
ambulance services. Ambulance services fall 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 reimburse the copayment for ambulance services provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ExoDx Prostate IntelliScore (EPI) urine test. 
 
You asked the Plan to pre-approve the EPI test. You say that the EPI test is medically necessary as you hope to 
avoid a biopsy. The Plan denied your request. The Plan says this procedure is not medically necessary and the 
requested provider is out-of-network. 
 
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 EPI test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation has not demonstrated that the requested ExoDx Prostate IntelliScore (EPI) urine test 
has a proven relation to the management and outcome of this enrollee's medical condition. 
 
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 EPI test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ExoDx Prostate IntelliScore (EPI) urine test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic mattress (E1399). 
 
You asked the Plan to pre-approve the mattress. You say that this item is medically necessary. The Plan denied 
your request. The Plan says the requested mattress is not a type that is covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic mattress (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1833) provided July 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items ordered following the non-covered visit are likewise non-
covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) provided July 9, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and harness for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
 
 
control), or an attendant control. The enrollee's upper extremity strength and function of independence in 
grooming and feeding are sufficient for the enrollee to control any power options through their own individual 
switches. The enrollee does not need to operate 3 ore more powered seating actuators through the drive control. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller and harness for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a chemodenervation procedure (64615) 
using Botox injection (J0585) received on March 3 and May 11, 2020. 
 
You asked the Plan to waive the cost-sharing for a chemodenervation procedure using Botox. You say that you 
were not informed you would have to pay this cost-sharing. The Plan denied your request. The Plan says the 
correct cost-sharing was applied. 
 
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 each Medicare-covered Part B drug and a $30 copayment for services obtained from a 
specialist.  
 
You have been asked to pay $219.72, or a $30 copayment plus $189.72 coinsurance (or 20% of the Plan-
allowed amount of $948.60) for a chemodenervation procedure using Botox performed on March 3, 2020. You 
have also been asked to pay $201.96, or $189.72 coinsurance plus $12.24 coinsurance (or 20% of the Plan-
allowed amount of $61.20) for Botox injections received on May 11, 2020. 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-sharing for a chemodenervation procedure (64615) using Botox injection (J0585) received on 
March 3 and May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305) provided on June 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services should be covered. The Plan denied 
your request. The Plan says these services were not emergent. There were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
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 the lab services (88305) provided on June 24, 2020 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on 
August 11, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have never had to 
pay in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 10% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies provided on August 11, 2020. The allowed amount is $50.60 and 10% 
of that is $5.06.  
 
You have been asked to pay the total coinsurance amount of $5.06 for DME and related supplies. DME and 
related supplies fall within the DME and related 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for DME and related supplies provided on August 11, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on May 5, 2020. 
 
You asked the Plan to pay for the lab services. You say that you were told you are not responsible for the 
services. The Plan denied your request. The Plan says that the services are not covered by Medicare. 
 
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. 
 
The lab services at issue were provided by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on May 5, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol Hcl tab 50mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested medication is denied as a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol Hcl tab 50mg for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on May 24, 
2020. 
 
You asked the Plan to pay for the provided items. You say that the documentation supports the services 
provided. The Plan denied your request. The Plan says there is a lack of evidence of disease, injury, or 
dysfunction. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records do not show sufficient objective documentation that the 
enrollee has experienced a recent injury, surgical procedure, or knee instability. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the knee orthosis and suspension sleeve provided on May 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital services provided on 
July 7, 2020 through July 12, 2020 and July 15, 2020 through July 19, 2020. 
 
You asked the Plan to waive the copayments for inpatient hospital services. You say that you should only owe 
one copay because each inpatient stay was related to the original. The Plan denied your request. The Plan says 
the copayment is correct. 
 
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 per admission for each medically necessary inpatient stay for inpatient hospital care.  
 
You have been asked to pay two $295 copayments for inpatient hospital services totaling $590. This service 
falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
inpatient hospital services provided on July 7, 2020 through July 12, 2020 and July 15, 2020 through July 19, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a heart rhythm monitor evaluation (93291) 
performed on June 3, 2020. 
 
You asked the Plan to waive the copayment for a heart rhythm monitor evaluation. You say that you never had 
to pay this charge before. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $35 
copayment for each visit to a specialist.  
 
You have been asked to pay a $35 copayment for a heart rhythm monitor evaluation. A heart rhythm monitor 
evaluation falls within the "Physician/Practitioner services, including doctor?s 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 a heart rhythm monitor evaluation (93291) performed on 
June 3, 2020.