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

 
We decided that the Plan does not have to pay for portable radiology services provided. 
 
You asked the Plan to pay for the portable radiology services. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 
services 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 portable radiology services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue (88305) provided by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology examination of tissue. You say that the services provided were 
medically necessary. 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 pathology examination of tissue (88305) 
provided 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 you received. 
 
You asked the Plan to pay for the services. You say that there was no need to be taken to the hospital. The Plan 
denied your request. The Plan says this is 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. 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 you received.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom orthoses (L1940, L2330). 
 
You asked the Plan to pre-approve the custom orthoses. You say that the braces are medically necessary. The 
Plan denied your request. The Plan says records do not support the need for custom braces. 
 
The Plan follows Medicare rules. Medicare rules say that custom orthoses are covered when medically 
necessary. 
 
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 custom orthoses. Our reviewer says 
that the bilateral custom orthoses are not medically necessary. Our physician reviewer found there is no 
documentation provided necessitating the requested custom orthosis. The physical exam is described in general 
terms that do not qualify or substantiate the request for bilateral Custom Braces. There is no documentation of 
an objective range of motion limitation in terms of degrees of restriction present in the ankle, foot, and digits. 
In addition, there are no results of specific foot/ankle instability maneuvers to confirm the presence of 
instability. 
 
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 custom orthoses have not been met. Therefore, we decided that the Plan 
does not have to pre-approve custom orthoses (L1940, L2330).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospitalization you had. 
 
You asked the Plan to waive the copayment for the inpatient hospitalization. You say that you were 
hospitalized without your consent, so you shouldn't have to pay this copayment. The Plan denied your request. 
The Plan says you were charged this copayment 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 $318 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a total of $636 ($318 per day for the two days of your stay =$636).  This 
copayment applies regardless of the reason for the admission. 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 inpatient hospitalization you had.  
 
Your complaint about the fact that you were admitted to the hospital without your consent is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, problem focused limited 
oral evaluation, and preventive procedure provided. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, problem focused limited oral evaluation, and 
preventive procedure. You say that the dentist's office was not open, so they were not able to look up your 
insurance information. The Plan denied your request. The Plan says these services are not covered benefits. 
 
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 the first 
intraoral periapical x-ray, problem focused limited oral evaluation, and preventive procedure provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays provided. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you feel this service should be covered because 
you went to a new dentist. You also say that you agreed to the x-rays to make sure your Parkinson symptoms 
had not caused any problems to your teeth. The Plan denied your request. The Plan says the number of times 
this procedure was performed has exceeded the contract limits. 
 
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, bitewing x-ray is limited to 1 per year. 
The record shows that you received bitewings , and your bitewings benefit has been exhausted.Therefore, we
decided that the Plan does not have to pay for the bitewing x-rays provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that these are your front teeth which 
you need in order to eat, and are experiencing pain. The Plan denied your request. The Plan says this service 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 pre-approve a 
maxillary partial denture.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imagining (MRI) of the abdomen (74181) and 
pelvis (72196). 
 
You asked the Plan to pre-approve MRIs of the abdomen and pelvis. You say that you need these tests because 
you have been in pain for months. The Plan denied your request. The Plan says that the records do not support 
this is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRIs of the abdomen and pelvis. Our 
reviewer says that the requested MRIs are medically necessary. Our physician reviewer found the record shows 
you are a 43-year-old female with ongoing left pelvic/groin pain, frequent urination, difficulty emptying 
bladder, and a urinary tract infection. You have seen a urologist and had a bladder scan 
showing urine retention, a gynecologist who ordered a pelvic ultrasound showing a fibroid, and were referred 
by the gynecologist to have an MRI. The MRI is justified in situations where urogenital system and pelvic 
organ definition is required to investigate chronic symptoms such as pain and incomplete bladder emptying 
such as in this case. Pelvic ultrasound and bladder scan has already been completed without a clear cause of 
your symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRIs of the abdomen and pelvis have been met. Therefore, we decided that the 
Plan has to pre-approve magnetic resonance imagining (MRI) of the abdomen (74181) and pelvis (72196).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis. 
 
You asked the Plan to pre-approve the orthosis.. You say that the brace is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a foot drop splint/recumbent positioning device 
and replacement interface will be denied as not reasonable and necessary in a beneficiary with foot drop who is 
non-ambulatory because there are other more appropriate treatment modalities.  
 
We looked at the file and Medicare rules. The record shows the enrollee is non-ambulatory. The requested 
device is not covered for enrollees that are non-ambulatory. Based on this information, we decided that 
Medicare rules for coverage of the orthosis. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ankle-foot orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out-of-
network (OON) provider at the in-network rate. 
 
You asked the Plan to pre-approve the out-of-network ophthalmology services. You say that you have used the 
out-of-network provider in the past and would like to continue seeing him. The Plan denied your request. The 
Plan says there are network providers available that can provided this service. If you use the out-of-network 
service, the out-of-network rate will be applied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network rate. Therefore, we decided that the Plan does not 
have to pre-approve the ophthalmology services to be provided by an out-of-network (OON) provider at the in-
network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided 
by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network 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 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 nursing facility care (99308) provided  by an
out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services (A0430, A0170, A0435, A0424) 
provided. 
 
You asked the Plan to pay for air ambulance services. You say that this should be covered. The Plan denied 
your request. The Plan says this transportation was not to the nearest facility. 
 
The Plan must follow Medicare rules. Medicare rules say that only mileage to the nearest appropriate facility 
equipped to treat the patient is covered. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was not transported to the nearest 
 
 
appropriate facility in this case. Based on this information, we decided that Medicare rules for coverage of air 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air 
ambulance services (A0430, A0170, A0435, A0424) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. The Plan denied your request. The Plan says 
the benefit limit for this service has been met. 
 
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, full mouth debridement (D4355) 
cannot be performed the same day as or less than 1 calendar year after an evaluation (D0120, D0150). The 
record shows that the enrollee received a comprehensive oral evaluation (D0150), and the 
enrollee's benefit limit for this service has been met. Therefore, we decided that the Plan does not have to pre-
approve a full mouth debridement (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a convenience item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the upper extremity 
(73221). 
 
You asked the Plan to pre-approve an MRI of the upper extremity. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the upper extremity. Our 
reviewer says that the services are necessary. Our physician reviewer found you had prior rotator cuff repair 14 
years ago. There is no history of trauma. The x-rays discussed in the denial are not necessary in an enrollee 
with a prior history of rotator cuff repair and no history of recent trauma. There is no potential finding on such 
x-rays which would obviate the need for an MRI in an enrollee with prior rotator cuff repair and dramatic 
decreased range of motion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the upper extremity have been met. Therefore, we decided that the 
Plan has to pre-approve a magnetic resonance imaging (MRI) of the upper extremity (73221).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment 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 May 29, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) and related 
accessories and components. 
 
You asked the Plan to pre-approve the PWC and accessories. You say that the records show that the requested 
PWC is needed along with the requested components. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for a Group 3 power wheelchair, a home assessment was not submitted so 
it is not clear if the enrollee's home cannot accommodate a power operated vehicle. Additionally, the enrollee 
does not meet the Medicare criteria for a power tile/recline system, the touch screen and head rest are not 
medically 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.  
 
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 PWC and accessories. Our reviewer 
says that the requested Group 3 PWC is not shown to be medically reasonable and necessary. Our physician 
reviewer found the documentation reveals that the patient has a personal mobility deficit but it is not clear on 
the documentation that this deficit impairs participation in MRADLs in the home. The patient was noted to be 
independent in feeding, toileting, meal prep, home management, grooming, dressing and min assist bathing. 
The patient's mobility deficit is currently helped by knee-ankle-foot orthoses (KAFOs) that require strap 
 
 
adjustment at the VA and quad cane and manual wheelchair.  
 
The documentation states that the patient's upper extremity pathology is making manual wheelchair use 
difficult but there are no objective exam findings on the physical exam of the arms consistent with these 
diagnoses. It is not clear that the patient's gait can be improved with KAFO strap adjustment which was 
recommended. The documentation reveals the patient was recently hospitalized duet to amphetamine and 
cocaine use causing acute encephalopathy. It is not clear that he has had a recent urine drug screen or whether 
he is still using illicit substances which would make operating a PMD unsafe. 
 
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 PWC and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (PWC) and related accessories and 
components.