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

We decided that the Plan does not have to pre-approve the SmartDrive manual wheelchair push-rim activated 
power assist system (E0986). 
 
You asked the Plan to pre-approve SmartDrive manual wheelchair push-rim activated power assist system. You 
say that you would like reconsideration because the member has a condition which is exacerbated by chronic 
wheelchair use. The Plan denied your request. The Plan says the member has a has manual wheelchair and 
sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to 
perform MRADLs during a typical day. 
 
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 SmartDrive manual wheelchair push-
rim activated power assist system E0986. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the beneficiary has a 
recent approval for a replacement of her Ultra-light manual wheelchair and the documentation supports she has 
sufficient strength to operate the wheelchair in the home to accomplish MRADLs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SmartDrive manual wheelchair push-rim activated power assist system E0986 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the SmartDrive manual 
wheelchair push-rim activated power assist system (E0986).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation services received on January 
15, 2020. 
 
You asked the Plan to pay for the services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this service is not a Medicare covered benefit except when medically necessary in 
an institutional special need plan (ISNP). 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transportation services received on January 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided on January 9, 2020, to 
February 8, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told that the charges would 
be 100% covered and you cannot afford 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 $0 
copayment for days 1-20 and a $160 copayment for days 21-49 for SNF care.  
 
You had a SNF stay from January 9, 2020, to February 8, 2020. You are not being charged a copayment for 
days 1-20 (January 9, 2020, to January 28, 2020). You are responsible to pay a $160 copayment for days 21-31 
(January 29, 2020, to February 7, 2020). $160 (copayment) x 10 (SNF days) = $1,600. 
 
You have been asked to pay the total copayment amount of $1,600 for a SNF stay. A SNF stay falls within the 
SNF 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 copayment for a SNF stay provided on 
January 9, 2020, to February 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87086) rendered by the out of 
network (OON) provider on June 1, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (87086) rendered by the out of network (OON) provider on June 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that your doctor thought you 
may have had colon cancer. You say that this was not an elective procedure. 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 $300 
copayment for outpatient surgery.  
 
You have been asked to pay a $300 copayment for an outpatient surgery. The correct copayment has been 
applied to the diagnostic colonoscopy that was provided. An outpatient surgery falls within the outpatient 
surgery 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 diagnostic colonoscopy 
provided by a participating provider on May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient hospital 
setting from June 10, 2020, to June 11, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not take any drugs on your 
own. You say that you only took what you were given. The Plan denied your request. The Plan 
says the drugs that you received while in an outpatient hospital setting are considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan says 
the requested drug is not covered under Medicare Part B. 
 
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 pay for the self-administered drugs 
provided in an outpatient hospital setting from June 10, 2020, to June 11, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for medical services you received on March 19, 2019. 
 
You asked the Plan to pay more for the medical services. You say that these bills should be covered in full. The 
Plan denied your request. The Plan says this out-of-network provider accepts Medicare, so they cannot bill you 
more than the Medicare-allowed rate that has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers that accept Medicare must accept the 
Medicare-allowed rates as payment in full. They are not allowed to balance bill either you or the Plan for any 
amounts above the Medicare allowable rate. 
 
In this case, this provider has already been paid the Medicare allowable rate, so they are not entitled to any 
additional payment from either you or the Plan. Since this provider is an out-of-network provider with the Plan, 
the Plan cannot force the provider to stop billing you inappropriately.  You do have the right, however, to 
contact 1-800-MEDICARE to ask for assistance with stopping this provider's inappropriate billing. 
 
Therefore, we decided that the Plan does not have to pay more for medical services you received on March 19, 
2019. Please note that this decision addresses only the March 19, 2019 date of service.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the osteogenesis stimulator is 
medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an osteogenesis stimulator is 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 osteogenesis stimulator. Our 
reviewer says that the requested stimulator is medically necessary. Our physician reviewer found the enrollee's 
spinal fusion procedure involved 3 or more vertebrae (C3-C5). Therefore as the enrollee had a multilevel spinal 
fusion surgery as defined by the criteria, the requirements for coverage of the requested item would be satisfied 
in this case. 
 
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 osteogenesis stimulator have been met. Therefore, we decided that the Plan 
has to pre-approve an osteogenesis stimulator (E0748).  
 
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 waive the copayment for the ophthalmology visit you had on June 
29, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that this was a follow-up visit 
for cataract surgery you had in August of 2019. You say that because you were out of the country, you didn't 
have the opportunity to have this follow-up visit until June. The Plan denied your request. The Plan says you 
were charged this copayment correctly.  The Plan says that the medical records indicate that you went to the 
ophthalmologist for complaints of blurred vision and you were diagnosed with posterior capsular opacification 
and posterior vitreous detachment.  The Plan says that this was not a post-operative exam. 
 
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 $40 
copayment for exams to diagnose and treat conditions of the eye by an ophthalmologist.  
 
You have been asked to pay a $40 copayment for the ophthalmology visit. 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 ophthalmology visit you had on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chromosome analysis (88264) provided on March 5, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for chromosome analysis. You say that the ancillary lab charges should be processed 
"In-Network" as the services were a crucial component in the diagnosis of the patient's medical condition 
and/or treatment. The Plan denied your request. The Plan says according to our records the rendering provider 
was not credentialed with Medicare on this date of service. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the provider at issue was 
not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's 
enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to 
pay for the chromosome analysis (88264) provided on March 5, 2019 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 an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing based on medical necessity. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the long-
term safety and efficacy of this procedure has not been established. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says you are receiving the 
appropriate care in the inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on June 13, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that your left foot is larger than your right. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus shot provided to the enrollee on June 17, 2020. 
 
You asked the Plan to pay for a tetanus shot under Medicare Part B. You say that this claim should be paid. 
The Plan denied your request. The Plan says this shot is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus shot under 
Medicare Part B. The Plan follows the same rules.  
 
The records do not show that the enrollee had been injured or directly exposed to any illness related to a tetanus 
shot under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a tetanus shot 
provided to the enrollee on June 17, 2020.  
 
Benefits for a tetanus shot under Medicare Part B may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services coded 88173 and the surgical 
pathology services coded 88305 provided on March 3, 2020. 
 
You asked the Plan to pay for the cytopathology services and the surgical pathology 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. 
 
We find that CPT codes 88173 and 88305 are not supported in the medical record. Specifically, these codes 
have a physician fee schedule professional component/technical component indicator of "1". The claim has a 
place of service of 23 (Emergency room- Hospital). Review of the file shows that the enrollee was inpatient at 
the hospital setting for this date of service. The professional interpretation was furnished in the same payment 
locality from where the TC was furnished. The Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting 
physician. Based on this information, we decided that Medicare rules for coverage of the cytopathology 
services and the surgical pathology services have not been met. Therefore, we decided that the Plan does not 
have to pay for the cytopathology services coded 88173 and the surgical pathology services coded 88305 
provided on March 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy procedure you had on May 8, 
2020. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you should not have to pay this 
copayment because it was a follow-up from a PET scan you had and the doctor couldn't see everything. 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 $50 
copayment for outpatient procedures and services.  
 
You have been asked to pay a $50 copayment for the biopsy. The biopsy falls within the outpatient procedures 
and services benefit category. This copayment applies regardless of the reason for this 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 biopsy procedure you had on May 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the occupational therapy evaluation 
(97166), therapeutic exercises (97110), and self-care management training (97535) provided. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy 
services. If you have more than one type of therapy during the same visit, a cost-sharing will apply to each 
type. A separate copayment applies to the initial evaluation and any re-evaluations. 
 
You have been asked to pay a $70 copayment ($35 + 9.73+ $25.27) for the outpatient rehabilitation therapy 
services provided. This amount includes a copayment for the initial evaluation and the individual cost sharing 
amounts applied for the therapy services provided on this visit. 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 adjust the copayment 
for the occupational therapy evaluation (97166), therapeutic exercises (97110), and self-care management 
training (97535) provided.