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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO). 
 
You asked the Plan to pre-approve HFCWO device. You say that the enrollee is unable to effectively clear 
secretions on his own and this device is medically necessary. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because the enrollee does not meet any of the requirements for 
the device. 
 
 
 
The Plan follows Medicare rules. Medicare rules state that a HFCWO device is only covered if the clinical 
criteria listed in the previous section have been met. 
 
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 HFCWO device. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested HFCWO device. Our physician reviewer 
found the enrollee has chronic obstructive pulmonary disease (COPD) but does not have a covered diagnosis 
such as cystic fibrosis or bronchiectasis. There is insufficient evidence that HFCWO is beneficial in COPD or 
chronic bronchitis. HFCWO is not medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation device (HFCWO).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gait training therapy services coded 97116 provided on 
October 9, 2019. 
 
You asked the Plan to pay for the gait training therapy 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). 
 
We find that CPT code 97116 is not supported in the medical record. Specifically, this service was billed and 
identified as part of another code (97530, Therapeutic activities, direct (one-on-one) patient contact (use of 
dynamic activities to improve functional performance), each 15 minutes) billed on the same date of service. 
Code 97116 was not billed with an appropriate modifier to be billed with code 97530. Based on this 
information, we decided that Medicare rules for coverage of the gait training therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for the gait training therapy services coded 
97116 provided on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on August 11, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you were never charged 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 a $5 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $5 copayment for an ECG. An ECG 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 
an ECG provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient port removal procedure you 
had on July 13, 2020. 
 
You asked the Plan to waive the deductible for the outpatient procedure. You say that you were not aware of 
this deductible. The Plan denied your request. The Plan says you were charged this deductible 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 $250 annual deductible for outpatient services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 annual 
deductible for outpatient services. This cost sharing is a contractual obligation that had not been met at the time 
the outpatient procedure was received on July 13, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for the outpatient port removal procedure you had on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), platelet rich plasma, any site, including 
image guidance, harvesting and preparation when performed (CPT Code 0232T) to help with hip pain. 
 
You asked the Plan to pre-approve the injection. You say that your quality of life has decreased as you have 
trouble with walking, getting dressed, putting shoes on, and normal activities of daily living. The Plan denied 
your request. The Plan says the shot is not proven in medical studies to improve treatment outcomes. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the effectiveness of platelet rich plasma injections to treat hip pain has not been established. 
Platelet rich plasma injections are considered experimental/investigational in nature. As such, platelet rich 
plasma injections to treat hip pain are not medically reasonable and necessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), platelet rich plasma, any site, including image guidance, harvesting and 
preparation when performed (CPT Code 0232T) to help with hip pain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you are requesting reconsideration 
of the denial as the services are medically necessary. The Plan denied your request. The Plan says this service 
is considered experimental and investigational and not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CardioMEMS device (33289, C2624).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. 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 study. Our reviewer says that the 
requested study is not considered medically reasonable and necessary in this case. Our physician reviewer 
found coverage criteria for a repeat split-night PSG are not met. This enrollee has been found to have OSA. It 
would be reasonable and standard practice to start auto-titrating CPAP. If this is not successful in eliminating 
the sleep-disordered breathing, than a full-night attended PAP titration may become necessary. There is no 
reason to do another split-night study because the diagnostic portion is not needed. There is no evident 
 
 
justification for the study to be out of network. The requested PSG is not medically necessary. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee requires 
more transportation trips. The Plan denied your request. The Plan says that the enrollee has exhausted this 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite of 1 surface (D2330), 
posterior resin-based composite of 1 surface (D2391), posterior resin-based composite of 2 surfaces (D2392), 
crown (D2751), and core buildup, including any pins when required (D2950) provided on March 3, 2020, and 
June 3, 2020. 
 
The enrollee asked the Plan to pay for the resin-based composites, crown, and core buildup. The Plan denied 
the enrollee's request. The Plan says the enrollee's dental services processed correctly according to their plan 
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 enrollee is responsible for a 20% 
coinsurance for each resin-based composite (codes D2330, D2391, and D2392), a 50% coinsurance for a crown 
(D2751), and a 50% coinsurance for a core buildup, including any pins when required (D2950). Therefore, we 
decided that the Plan does not have to pay for the anterior resin-based composite of 1 surface (D2330), 
posterior resin-based composite of 1 surface (D2391), posterior resin-based composite of 2 surfaces (D2392), 
crown (D2751), and core buildup, including any pins when required (D2950) provided on March 3, 2020, and 
June 3, 2020.  
 
 
 
Please note: The Plan confirmed that a $300 payment was issued to the provider for the crown (D2751) on 
October 2, 2020. The records show that the Plan received an updated invoice from the provider showing that 
the enrollee's financial responsibility has been reduced from $443.50 to $1.50 for the services provided on 
March 3, 2020, and June 3, 2020. Please contact the Plan for any information regarding this change.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound was necessary in 
order to diagnose breast cancer. 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 $100 
copayment for ultrasounds.  
 
You have been asked to pay the allowed amount of $93.54, which is less than the $100 copayment for an 
ultrasound. An ultrasound 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 an ultrasound provided on 
August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140, D7210, D0330) provided on July 
22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services received out-of-network are not a covered benefit. 
 
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 dental services (D0140, D7210, D0330) 
provided on July 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the type of service requested by the member's doctor is not supported because research 
has not found it to be helpful for the member's condition or for what is causing their pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the distraction device is experimental and more research is needed to show safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
 
 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection you received 
from an out-of-network provider on August 4, 2020. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you cannot afford this 
coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% 
coinsurance for Medicare Part B drugs received from an out-of-network provider.  
 
You have been asked to pay 50% coinsurance for the denosumab injection. 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 the denosumab injection you received from an out-of-network provider on August 
4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427, A0425) 
provided on April 2, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like this 
copayment erased. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 ambulance services.  
 
You have been asked to pay a $75 copayment for the ambulance services. The services provided 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 waive the copayment for the ambulance 
services (A0427, A0425) provided on April 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy, infusion therapy, not otherwise 
classified; administrative services, professional pharmacy services, care coordination, and all necessary 
supplies and equipment (drugs and nursing visits coded separately), per diem (CPT Code S9379 X23). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Medicare guidance says status code 
'I' Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these 
services. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy, infusion 
therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, 
and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (CPT Code 
S9379 X23).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a non-
participating provider on March 13, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you think you are being over 
charged. The Plan denied your request. The Plan says the correct copayment has been 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 $20 
copayment for physician/practitioner services/out-of-network/primary care provider.  
 
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the 
physician/practitioner services/out-of-network/primary care provider 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 by a non-participating provider on March 13, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) of thorax 
(71250) provided on September 4, 2020. 
 
You asked the Plan to waive the copayment for CT of thorax. You say that you were not told there would be a 
copay. The Plan denied your request. The Plan says the copay 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 $275 
copay for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $107.98 out of the $275 copay for CT of thorax. This service 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 computed tomography (CT) of thorax (71250) provided on September 4, 2020.