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

We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that no one told you that 
your transportation was limited to a certain amount. The Plan denied your request. The Plan says you exhausted 
your 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 20 one-way 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 24 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, portable, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT Code K0820). 
 
You asked the Plan to pre-approve the DME. You say that you need the power wheelchair. The Plan denied 
your request. The Plan says you can walk with or without the assistance of a cane and a four wheeled walker 
with seat. 
 
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 DME. Our physician reviewer 
found the requested power wheelchair/power operated vehicle is not medically necessary per Medicare's LCD 
L33789. The documentation does not reveal that you have a personal mobility deficit that impairs participation 
in MRADLs in the home. Your mobility can be helped by a cane or walker. A power mobility device is noted 
to likely not appreciably improve your ability to participate in your activities of daily living in the home. The 
requested power mobility device 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up 
to and including 300 pounds (CPT Code K0820).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Synavasure lab test. 
 
You asked the Plan to pre-approve the test. 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 test. Our reviewer says that the 
requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found 
care must be taken with interpretation of the lateral flow test when relying on its results for the intra-operative 
diagnosis of PJI. The review has determined that the requested Synavasure lab test in this case is not medically 
reasonable or 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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Synavasure lab test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT Code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the requested power operated vehicle K0800 is not medically necessary per LCD L33789. The 
documentation reveals that you have a personal mobility deficit but it is not clear that this deficit significantly 
that impairs participation in MRADLs in home. There is no gait evaluation or detailed neuromuscular exam of 
the bilateral upper extremities (BUE) or bilateral lower extremity (BLE). Your mobility deficit is currently 
helped by a cane and it is not clear why the deficit could not also be alleviated with a manual wheelchair or 
walker. The documentation is not clear that you can safely maneuver the PMD in the home. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (CPT Code K0800).
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 (CPT Code 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 this service is considered experimental and investigational. 
 
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 device is not medically needed. It is experimental and more research is needed to show 
safety and efficacy of the device. 
 
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 (CPT Code 22869) and (CPT Code 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electronic connection wheelchair accessory (E2311) 
provided on June 4, 2020. 
 
You asked the Plan to pay for an electronic connection wheelchair accessory. You say that this should be 
covered. The Plan denied your request. The Plan says this item was not shown to be necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that code E2311 describes the electronic components 
that allow the beneficiary to control two or more of the motors listed above from a single interface. The rules 
also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier 
sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. No medical records to supported that the item at issue was necessary 
to control two or more motors has been submitted. The file shows that you were notified of non-coverage prior 
to this item being provided. Based on this information, we decided that Medicare rules for coverage of an 
electronic connection wheelchair accessory have not been met. Therefore, we decided that the Plan does not 
have to pay for an electronic connection wheelchair accessory (E2311) provided on June 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided November 
16, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that sending report for reconsideration. Please review 
and reprocess for payment. The Plan denied your request. The Plan says this claim processed correctly as this is 
a duplicate of previously paid claim. 
 
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 billing of code 71045 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for radiologic examination, chest (71045) provided November 16, 
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an MRI of lower extremity (73721) 
performed on February 6, 2020, 2 chest X-rays (71046) performed on March 18 and June 4, 2020, and an EKG 
procedure (93306) performed on June 9, 2020. 
 
You asked the Plan to waive the cost-sharing for an MRI of lower extremity, 2 chest X-rays, and an EKG. You 
say that you never had a copayment or coinsurance before. The Plan denied your request. The Plan says the 
correct cost-sharing 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 20% 
coinsurance for Medicare-covered advanced imaging services and for Medicare-covered diagnostic procedures 
and tests. Your contract also says that enrollees must pay a $15 copayment for Medicare-covered X-rays. 
 
You have been asked to pay $48.00, or 20% coinsurance of the Plan-allowed amount of $239.99, for an MRI of 
lower extremity. You have also been asked to pay $101.29, or less than 20% coinsurance of the Plan-allowed 
amount $2,238.00, for an EKG. Lastly, you have been asked to pay a $15 copayment for each of 2 chest X-
rays. An MRI of lower extremity, 2 chest X-rays, and an EKG fall 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 cost-sharing for an MRI of lower extremity (73721) performed on February 6, 2020, 2 chest X-rays (71046) 
performed on March 18 and June 4, 2020, and an EKG procedure (93306) performed on June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammography, film processed 
to produce digital image analyzed for potential abnormalities, unilateral, all view (G0207) provided May 8, 
2020. 
 
You asked the Plan to waive the copayment for diagnostic mammography. You say that the results from your 
mammogram completed 03/06/2020 suggested that you needed additional imaging outside of your screening 
mammogram and you feel you should not be liable. The Plan denied your request. The Plan says the claim was 
processed and the correct copayment applied per the plan benefits. 
 
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 
additional cost-share when other services are performed for breast cancer screening (mammograms).  
 
You have been asked to pay $100 for the diagnostic mammography. The diagnostic mammography falls within 
the breast cancer screening (mammograms) benefit category. The records show that an initial mammogram was 
provided on March 6, 2020. The plan will cover for one screening mammogram every 12 months. 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 diagnostic mammography, film processed to produce digital image 
analyzed for potential abnormalities, unilateral, all view (G0207) provided May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on June 24, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient 
visit (99214) provided on June 24, 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 the home health visit provided on September 23, 2019. 
 
You asked the Plan to pay for Home visit for the evaluation and management of an established patient (99350). 
You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records 
show the submitted services were performed by an LVN and billed by a physician. 
 
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 99350 is Home visit for the evaluation and management 
of an established patient. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, there is no documentation 
that a physician was present during the home visit. Based on this information, we decided that Medicare rules 
for coverage of Home visit for the evaluation and management of an established patient (99350) have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health visit provided on September 
23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says medical necessity 
cannot be determined with the information provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. 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 pay for the lab services provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cochlear implant lithium ion battery replacement provided 
on September 9, 2019. 
 
You asked the Plan to pay for the cochlear implant lithium ion battery replacement. The Plan denied your 
request. The Plan says the Plan requires utilization of network providers when possible and available, and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider and the referring provider in this case are not network providers with the Plan. The Plan 
did not pre-approve the services. 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 a cochlear implant lithium ion battery replacement 
provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a 
participating provider on September 1, 2019, to September 19, 2019. 
 
You asked the Plan to waive the copayment for a skilled nursing stay. You say that this should be fully 
covered. 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 $0 
copayment per day for days 1-20. There is a $172 copayment per day for days 21-100 for skilled nursing care.  
 
You have been asked to pay a $0 copayment per day for days 1-20. There is a $172 copayment per day for days 
21-28 for a skilled nursing stay. The total amount you are being asked to pay is $1,204 ($172 x 7 days = 
$1,204). A skilled nursing stay falls within the skilled nursing 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 skilled nursing stay provided by a participating provider on September 1, 2019, to 
September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient therapy provided from May 11, 
2020, through May 29, 2020. 
 
You asked the Plan to waive the copayments for outpatient therapy. You say that you say that you were trying 
to better yourself not knowing you would be hit with money out-of-pocket. You say that your budget is full. 
The Plan denied your request. The Plan says the copayments applied 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 $35 
copayment for each in-network, Medicare-covered therapy visit. 
 
You have been asked to pay a $35 copayment for each outpatient therapy visit. The total amount you owe is 
$245 ($35/visit x 7 visits = $245). Outpatient therapy falls within the "Outpatient rehabilitation 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 copayments for outpatient therapy provided 
from May 11, 2020, through May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on February 11, 2020, to March 10, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that these were post-op visits. 
You say that you should not have a copayment for this. 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 $40 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $40 copayment for each specialist office visit. The total amount you are being 
asked to pay is $80 ($40 x 2 visits = $80). Post-op office visits are subject to a copayment; therefore, the 
correct copayments have been applied. A specialist office visit falls within the physician/practitioner 
services/specialist visit 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 specialist 
office visit provided by a participating provider on February 11, 2020, to March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the nitrous oxide provided from June 25, 2020, to June 29, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you did not want or need the nitrous. You say 
that you were numbed enough before even receiving the nitrous. You also say that you should not be charged 
for something you did not want or know that you were getting. The Plan denied your request. The Plan says 
nitrous oxide is not listed as a covered service. The Plan also says that you signed a treatment plan stating that 
nitrous oxide would be used and that it would not be 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
nitrous oxide provided from June 25, 2020, to June 29, 2020.