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

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) and a knee orthosis 
with suspension sleeve (L1851, L2397) provided to the enrollee on February 19, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist 
orthosis (L3960) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on 
February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that this physician has been highly 
recommended to you by a friend who is a Plan patient and was allowed to go out-of-network for surgery. The 
Plan denied your request. The Plan says the available medical records have been reviewed and do not suggest a 
medical urgency/emergency for the request and the Plan has the medical expertise to evaluate and treat your 
scoliosis in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient office visit (99204) with an in-network 
tertiary rheumatologist. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that you really need to get a second 
opinion from the requested provider and you know you can go to this facility because the plan has already 
approved other services there. The Plan denied your request. The Plan says the medical records do not show 
any special needs or medical problems that requires higher level of care. The enrollee has been approved to see 
another contracted non-tertiary level Rheumatologist. 
 
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 outpatient office visit. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that a tertiary rheumatology referral is currently 
medically necessary or reasonable. 
 
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 outpatient office visit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient office visit (99204) with an in-network tertiary rheumatologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 10, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services rendered by the out of network (OON) provider on  
February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of the ulnar shaft fracture (25545) 
rendered by the out of network (OON) provider on April 14, 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 open treatment of the ulnar shaft fracture (25545) rendered by the out of network (OON) 
provider on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alcohol or peroxide, per pint (A4244) alcohol wipes, per 
box (A4245) wound cleansers, any type(A6260)   skin sealants, moisturizers (A6250) and non-covered items 
(A9270). 
 
You asked the Plan to pre-approve the alcohol or peroxide, alcohol wipes, wound cleansers and skin sealants, 
moisturizers. You say that you are requesting an appeal for initiation of services and supplies. The Plan denied 
your request. The Plan says these items are not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that Medicare does not pay for OTC items and the alcohol or peroxide, 
alcohol wipes, wound cleansers and skin sealants, moisturizers are OTC items. The items at issue in this appeal 
does not serve a purpose that is primarily medical in nature. These items are available to the general public and 
would be helpful even to those who are not sick or injured.   Therefore, we decided that the Plan does not have 
to pre-approve alcohol or peroxide, per pint (A4244) alcohol wipes, per box (A4245) wound cleansers, any 
type(A6260)   skin sealants, moisturizers (A6250) and non-covered items (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 9, 2019 through October 
28, 2019 by an in-network provider. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says you paid upfront to provider a total of $521 for services 
rendered in October 2019. The Plan states your total member responsibility for those services (after the Plan 
paid to provider) is $320. The Plan states they reached out to the provider and confirmed that they sent you 
three (3) checks to reimburse for what was owed to you ($201). 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
Review of the file show that you received services provided from October 9, 2019 through October 28, 2019 by 
an in-network provider. Your EOC states, "enrollees must pay a $20 copayment for in-network Medicare-
covered chiropractic services. The Plan cover only manual manipulation of the spine to correct subluxation. 
Other services performed by a chiropractor are not covered." Therefore, you are asked to pay a $20 copayment 
for only manual manipulation of the spine to correct subluxation. If you received other services performed by a 
chiropractor, they are not covered and you are responsible for those services. The records show that the service 
at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for 
the services provided from October 9, 2019 through October 28, 2019 by an in-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for home health services provided on May 19, 2020 by an OON provider. You say 
that the services were necessary. The Plan denied your request. The Plan says prior authorization was not 
requested or received for the services, therefore coverage criteria has not been met. 
 
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 home health services provided on May 19, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that 
an implant was surgically placed last year, and an abutment and crown are needed in order to complete the 
procedure. You also say that if implants are not restored with abutment and crown, the implant will experience 
bone loss. The Plan denied your request. The Plan says these services are not covered under the enrollee's 
benefit package. 
 
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 pre-approve a 
custom fabricated abutment (D6057) and an implant supported crown (D6066).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening laboratory tests provided on February 20, 2020. 
 
You asked the Plan to pay for lab tests. You say that you do not have information on the enrollee's insurance 
requirements, limitations, or conditions and process the specimen sent by the treating provider. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because these tests are not a 
Medicare benefit for the diagnoses listed and were performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
screening laboratory tests provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this 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. 
 
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 a 
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (K0040, E0978, E2311, 
E1028) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. 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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the adjustable angle footplate is not medically reasonable and necessary and does not need to be 
billed separately. This feature is already included in the approved power wheelchair and would exceed the 
enrollee's medical needs. The enrollee does not have weak upper body muscles, upper body instability or 
muscle spasticity that requires a separate pelvic strap/safety belt. The enrollee does not need the requested 
safety belt, as this is included in the requested group 2 power wheelchair, and would exceed the enrollee's 
needs. The documentation does not support the sole function of E2311 will be for a power seat elevation 
feature or a power standing feature. It is not necessary outside of this and the enrollee has sufficient strength 
and function in the upper extremities to control any power options through their own switches. The swingaway, 
retractable or removable hardware (E0128) for joystick swing away is not medically necessary as the  patient 
was already approved for a K0180 joystick with adjustable height/hardware therefore this request exceeds the 
enrollee's medical need as these appears to be the same item that was approved already. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (K0040, E0978, E2311, E1028) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care, per day (99220) rendered by the 
out of network (OON) provider on January 9, 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 initial observation care, per day (99220) rendered by the out of network (OON) provider on 
January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health services you 
received from January 21, 2020, through February 3, 2020. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you were 
involuntarily admitted, 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 $350 
copayment per day for days 1-4 for inpatient mental health care.  
 
You have been asked to pay a $350 copayment per day for days 1-4 for the inpatient mental health services. 
There is nothing in your Evidence of Coverage to indicate that this cost sharing obligation is waived if the 
admission is involuntary. 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 inpatient mental health 
services you received from January 21, 2020, through February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on March 5, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services rendered by the out of network (OON) provider on  
March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 19, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage of comprehensive genomic profile testing is limited to one test per specimen. 
 
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 the documentation in the case file does not show that the testing was billed with a correct CPT 
code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant360 testing provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that your facility does not have information on the 
enrollee's insurance requirements, limitations, or conditions. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the 
ordering provider is also out-of-network with the Plan. 
 
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 medical services provided on February 6, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemodenervation provided on November 
19, 2019. 
 
You asked the Plan to waive the copayment for chemodenervation. You say that you disagree with the charges 
because no surgery took place. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received chemodenervation on November 19, 2019. Chemodenervation is considered an outpatient 
surgical procedure. Therefore, you are responsible to pay the allowed amount of $230.09, which is less than the 
$295.  
 
You have been asked to pay $230.09 for chemodenervation. Chemodenervation falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 chemodenervation provided on 
November 19, 2019.