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

We decided that the Plan does not have to waive the copayment for an ECG provided on June 9, 2020.
You asked the Plan to waive the copayment for an ECG. You say that you went to the hospital because your
primary care physician was not available to perform the test. 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 each diagnostic test completed in a physician or freestanding facility and a $45 copayment for
each diagnostic test completed in an outpatient hospital facility.
You have been asked to pay a $45 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 June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on August 19, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think you 
should have to pay for this. You say that this is too expensive. 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 $200 
copayment for inpatient hospital care.  
 
You have been asked to pay a $200 copayment for an inpatient hospital stay admission. An inpatient hospital 
stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an inpatient hospital stay provided by a participating provider on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the criteria applies in this case. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found more conservative 
measures are needed. There are no red flags. A trial of physical therapy is recommended. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup of teeth 19 & 20 (D2950). 
 
You asked the Plan to pre-approve core buildup of tooth 19 & 20. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not covered. 
 
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. If a dental item or service is 
not listed in the benefit chart or listed with NC, then it is not covered. 
 
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 of teeth 19 & 20 (D2950).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to lower the co payment for the diagnostic ultrasound provided.

You asked the Plan to lower the co payment for the diagnostic ultrasound. You say that the co payment for an ultrasound procedure is inordinately high.The Plan denied your request. The Plan says you were charged this co  payment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $135 co payment for outpatient diagnostic tests. You have been asked to pay a $135 co payment for the diagnostic ultrasound.The diagnostic ultrasound falls within the outpatient diagnostic tests 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 lower the co payment for the diagnostic ultrasound provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 4, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician?s 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 physician's services provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pair of depth shoes and three pairs of inserts. 
 
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 not covered. 
 
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 and covers one 
pair of depth shoes and three pairs of inserts per calendar year. 
 
The file shows that you have diabetic foot disease. You previously received one pair of depth shoes and three 
pairs of inserts for which the Plan approved and paid on May 7, 2020. The Plan covers these services only once 
per year. Therefore, we decided that the Plan does not have to pre-approve a pair of depth shoes and three pairs 
of inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approverepetitive transcranial magnetic stimulation (rTMS).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that rTMS therapy is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has recurrent, severe major depressive disorder and is requesting 36 sessions of rTMS therapy. 

Based on the submitted records, the enrollee does not meet the criteria for coverage, as there is no documentation thatthe threshold of resistance to medication criterion is met. The services are therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approverepetitive transcranial magnetic stimulation (rTMS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 5, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says members 
must use network (contracted) providers to get medical care and services. The only exceptions are emergencies, 
urgently needed services when the network is not available, and cases in which the Plan authorizes use of out-
of-network providers. 
 
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 
laboratory 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 laboratory services provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital care provided from August 6, 2020, to August 14, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that you would like this copayment waived and reprocessed to a previous admission.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 $360 copayment per day for days 1-5, $0 copayment for all addition days for inpatient hospital care. You have been asked to pay a total copayment of $1800 for the 8 days of inpatient hospital care ($360 x 5). The services provided fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive thecopayment forthe inpatient hospital care provided from August 6, 2020, to August 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
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. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five pontics (D6240 x5), two retainer crowns (D6750 
x5), and an extraction (D7210). 
 
You asked the Plan to pre-approve the pontics, retainer crowns, and extraction. You say that you are in pain 
and need these services approved. The Plan denied your request. The Plan says these services are not covered 
under your benefit plan. The Plan also says that these services are all restorative in nature, and you only have 
coverage for preventive services. 
 
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 five 
pontics (D6240 x5), two retainer crowns (D6750 x5), and an extraction (D7210).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there has been enough time since the start of care to instruct and transition 
the enrollee to a home program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The patient has had extensive therapy for this condition and 
it does not appear that the patient requires the unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee was instructed in an independent exercise program. The  specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the power wheelchair accessories provided on March 18, 2020.
You asked the Plan to pay for the power wheelchair accessories. You say that the proof of delivery was
submitted. The Plan denied your request. The Plan says that there is no proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record contains a signed Delivery Ticket. Therefore, we decided that the Plan has to pay for the power
wheelchair accessories provided on March 18, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair/transfer bench. 
 
You asked the Plan to pre-approve a shower chair/transfer bench. You say that you are not able to shower 
alone. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair/transfer bench.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ECG provided on February 26, 2020. 
 
You asked the Plan to waive the deductible for an ECG. You say that you were not aware that the provider was 
out-of-network. 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. Your 
contract with the Plan says that there is a $1,000 deductible for out-of-network outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You received an ECG on February 26, 2020, with an out-of-network provider. The record shows that you had 
paid $0 toward the $1,000 deductible. Therefore, you are responsible to pay the total allowed amount of 
$251.05.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible for out-of-network outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
an ECG was received on February 26, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for an ECG provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and treatment from an out of network
(OON) provider.
You asked the Plan to pre-approve the consultation and treatment from an OON provider. The Plan denied your
request. The Plan says the services needed are available with the Plan network. The Plan says that it is not
medically necessary to receive the care being requested from an OON 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 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. Therefore, we decided that the Plan does not have to pre-approve
consultation and treatment from an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 6, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 21, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the Place of Service (POS) code reported is not supported by the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted has a discrepancy in 
regard to the POS code. Medicare rules for coverage of this service have not been met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on January 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services provided on July 9, 2020. 
 
You asked the Plan to waive the deductible for podiatry services. You say that you disagree with the out-of-
network 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. Your 
contract with the Plan says that there is a $1,750 deductible for out-of-network podiatry services.  
 
You received out-of-network podiatry services on July 9, 2020. The record shows that you had paid $0 toward 
the $1,750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed 
amount of $220.66.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,750 
deductible for podiatry services. This cost sharing is a contractual obligation that had not been met at the time 
podiatry services were received on July 9, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for podiatry services provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMycophenolate for the enrollee.You asked the Plan to pre-approvethis drug. You say that this medication is controlling the enrollee's symptoms.The Plan denied your request. The Plan says that this is not covered under 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 pre-approveMycophenolate for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights