Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 23, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 physical therapy services provided on June 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) provided June 7, 
2020. 
 
You asked the Plan to pay for ALS routine disposable supplies. You say that the original hospital in Gilbert, 
AZ was not able to treat you, therefore they sent you by ambulance to another hospital in Phoenix, AZ. The 
Plan denied your request. The Plan says payment for this service is included in the ambulance service and is 
not separately payable. 
 
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, we have confirmed that code ALS 
routine disposable supplies has a bundled relationship with code A0426 and cannot be paid as billed. Oxygen 
and other items and services provided as part of the transport are included in the fee schedule base payment rate 
and are not separately payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) 
provided June 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on June 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for occupational therapy. You say that you would like this appeal reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider or the skilled nursing facility. 
 
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 occupational therapy provided on June 26, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99205) provided on May 28, 2020. 
 
You asked the Plan to pay for a new patient office visit. You say that this is supported by the documentation. 
The Plan denied your request. The Plan says this was not billed with a correct code. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of 
care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of 
moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the record shows that the 
enrollee was seen by the same provider on May 19, 2020, meaning the enrollee was not a new patient on this 
date of service. Based on this information, we decided that Medicare rules for coverage of a new patient office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit 
(99205) provided on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services you received from June 9, 2020, to June 11, 2020.
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you didn't choose to stay at the hospital, 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 $300 copayment per day for days 1-4 for inpatient mental health care. You have been asked to pay a $300 copayment per day for the inpatient mental health services. 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 inpatient mental health services you received from June 9, 2020, to June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records to document a trial and failure of surgical treatment. 
 
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 stimulator. Our reviewer says that 
the requested stimulator is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have undergone surgical intervention for their condition. Nor was there 
adequate documentation showing/supporting that the enrollee was not a candidate for surgery. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on July 15, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
outpatient hospital services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on July 15, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting (76377). 
 
You asked the Plan to pre-approve 3D rendering with interpretation and reporting. You say that you are 
appealing the denial for CPT code 76377. Urgent as the enrollee is scheduled 10/04/20. The enrollee is 
experiencing cognitive impairment. The Plan denied your request. The Plan says this request is not medically 
necessary as the use of this imaging is limited to research studies and is considered investigational and 
experimental. 
 
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 3D rendering with interpretation and 
reporting. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the use of 3D rendering with interpretation and reporting, 
while technologically feasible, has largely been limited to the research setting. Nor does such post-imaging 
processing lead to any form of meaningful improvements in the diagnostic process. The specific findings made 
by such 3D rendering are also non-specific. Rather current literature has not shown a definitive correlation 
between such findings and specific diagnoses. In this setting such services can be said to otherwise exceed the 
member's clinical needs. Nor would such services be expected to be as beneficial as an existing and available 
medically appropriate alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D rendering with interpretation and reporting have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting (76377).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Computed tomography (CT) sinus (70486) 
 
You asked the Plan to pre-approve CT scan of sinus. You say that the enrollee is a 94 year old woman with 
new onset head pressure and sinus pressure. Please approve the brain CT and sinus CT requested. The Plan 
denied your request. The Plan says that the requested service does not seem reasonable or necessary at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan of sinus. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has a history of headaches. She was seen for neurology evaluation regarding her 
headaches in October 2020. At that time there was a suspicion of sinus related headaches. According to the 
current guidelines from the American College of Radiology on imaging for sinusitis: Sinus CT imaging is 
appropriate per clinical judgment in associated complications including headache, facial pain, swelling, orbital 
proptosis or cranial nerve palsies. In this case as the enrollee had facial pain and headaches, it would be 
consistent with practice guidelines to perform a CT scan of the sinuses. In as much it can therefore be said that 
the requested service would be 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 CT scan of sinus have been met. Therefore, we decided that the Plan has to pre-
approve Computed tomography (CT) sinus (70486)  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy provided from May 8, 
2020, to May 29, 2020. 
 
You asked the Plan to waive the copayments for the radiation therapy services. You say that you only had 8 
radiation therapy sessions, so only 8 copayments should apply. The Plan denied your request. The Plan says 
you were charged these copayments 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 $60 
copayment for radiation therapy services (including technician materials and supplies).  
 
Records show that from May 8, 2020, to May 29, 2020, you had ten separate radiation therapy visits. The two 
sessions you are appealing specifically (dates of service May 8, 2020, and May 13, 2020) involved radiation 
therapy planning services and the custom molding and designing of the IMRT treatment device used in your 
treatment.  These services are considered radiation therapy services and a separate copayment is allowable for 
them. You have been asked to pay a $60 copayment for the radiation therapy services. 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 radiation therapy provided from May 8, 2020, to May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). The Plan denied your request. The Plan says the 
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 Plans 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 core 
buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable height armrests for a power wheelchair 
(PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are coded incorrectly. 
 
The Plan must follow Medicare rules. The rules say that adjustable height armrests are described by procedure 
code E0973. 
 
We looked at the file and Medicare rules. The requested adjustable height armrests were requested with code 
E1028. This code is incorrect. These items should be requested under code E0973. Therefore, we decided that 
the Plan does not have to pre-approve adjustable height armrests for a power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for chemotherapy drugs and lab services you 
received from January 21, 2020, to March 3, 2020. 
 
You asked the Plan to waive the cost sharing for the chemotherapy drugs and lab services. You say that you 
cannot afford this cost sharing. The Plan denied your request. The Plan says this coinsurance was charged 
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 for chemotherapy drugs and you must pay a $10 copayment for lab services.  
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs and a $10 copayment for each of the 
lab services you received. 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 chemotherapy drugs and 
lab services you received from January 21, 2020, to March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you lost your dentures. You also say that you 
cannot eat without dentures. The Plan denied your request. The Plan says dentures are covered once every 5 
plan years. The Plan also says that the frequency limit has been reached. 
 
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 frequency limit of dentures, 1 
every 5 plan years, has been reached. The record shows that you received a partial lower denture on June 12, 
2019 and a complete upper denture on May 20, 2019. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that echocardiography is indicated in the evaluation 
of derangements of valvular, myocardial and pericardial structure and function.  
 
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 services are considered medically reasonable and necessary in this case. Our physician reviewer 
found CMS criteria for stress echocardiograpy provide coverage for assessment of ischemia in a patient who 
has had a prior revascularization procedure (in this case CABG). In addition, given his DOT work, it is 
medically reasonable to assess for evidence of any silent or residual ischemia post bypass even with the lack of 
symptoms in this individual, especially considering the extent of his prior known diffuse 3 vessel coronary 
artery disease. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiogram for the enrollee.  
 
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 a power seat elevation system identified with code 
E2300. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system identified with code E2300.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71250) performed 
on July 5, 2019. 
 
You asked the Plan to waive the copayment for a CT scan of the thorax. You say that this was a really critical 
and necessary test. 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 $200 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $115.39 for a CT scan of the thorax. A CT scan of the thorax falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have 
been asked to pay less than or equal to 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 CT scan of the thorax (71250) performed on July 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental items. You say that you lost your dentures. You also say that you 
need denture replacements. The Plan denied your request. The Plan says partial dentures are covered once 
every 5 plan years. The Plan says the frequency limit has been reached. 
 
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 frequency limit for of 1 partial 
denture every 5 plan years has been reached. The record shows that the plan paid for partial dentures that you 
received on July 13, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper 
denture (D5211) and a partial lower denture (D5212).