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

We decided that the Plan does not have to pay for the electrocardiogram (EKG) and report rendered on 
November 27, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 93010 is not supported. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of 
a routine EKG interpretation and report. 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 pay for the 
electrocardiogram (EKG) and report rendered on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises provided on June 24, 2020. 
 
You asked the Plan to pay for the therapeutic exercises. 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 therapeutic exercises provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 21, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor has been your 
gynecologist for 20 years. You say that this should be covered as an annual visit, the same as a primary would 
be covered. The Plan denied your request. The Plan says the copayment 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 $45 
copayment for a specialty physician.  
 
You have been asked to pay $43.10, which is less than the standard $45 copayment for the office visit. The 
office visit falls within the "Physician/Practitioner services, including doctor?s office visits" benefit category. 
The records show that this was an annual surveillance checkup at an oncologist office due to a history of 
uterine sarcoma, which is not considered the covered annual exam. 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 office visit provided on May 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 11, 2020. 
 
You asked the Plan to pay for the services. You say that the enrollee was only covered by hospice until July 2, 
2020. The Plan denied your request. The Plan says this should be billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 2, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on July 11, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a finger amputation billed with CPT code 26951 for date of service 
January 22, 2020. 
 
You asked the Plan to pay for the finger amputation services. You say that the medical records provided 
support the service in dispute. The Plan denied your request. The Plan says that CPT code 2691 was not the 
most appropriate services performed for the Place of Service 11. The Plan says that, per CMS guidelines, Non-
Facility indicator identified as NA indicates that this procedure is rarely or never performed in the non-facility 
setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial reason is that this is a procedure which is noted to 
be rarely performed in the non-facility setting. However, there was no rule presented which categorically 
excludes coverage for this service in the non-facility setting. This means that the Plan has not substantiated 
their denial reason. Therefore, we decided that the Plan has to pay for a finger amputation billed with CPT code 
26951 for date of service January 22, 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 portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is necessary for the 
enrollee to attend medical appointments. The Plan denied your request. The Plan says this services the same 
function as the enrollee's oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home.  
 
The file shows that the enrollee has an oxygen concentrator. An oxygen concentrator serves the same purpose 
as a portable oxygen concentrator. The request also indicates a portable oxygen concentrator is being requested 
for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says rehab needs can safely be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. You are 
already ambulating household distances. Your care needs can be met at a lower level of care (ex. SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on August 25, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges 
because the labs were taken as part of your annual wellness exam. 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 $10 
copayment for laboratory tests.  
 
You received laboratory tests on August 25, 2020. Laboratory tests are not included in annual wellness exams. 
Therefore, you are responsible to pay the $10 copayment.  
 
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall 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 laboratory tests provided on August 25, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you the copayment for the ambulance services provided 
on January 31, 2019. 
 
You asked the Plan to reimburse you the copayment for the ambulance services. You say that you want to be 
reimbursed the copayment for the ambulance service. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $200 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $200 for these 
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 reimburse you the copayment for the ambulance services provided on 
January 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) provided on January 16, 2020. 
 
You asked the Plan to pay for the positron emission tomography (PET) with concurrently acquired computed 
tomography (CT). 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 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 a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 2 heavy duty, captains chair, 
patient weight capacity 301 to 450 pounds (CPT Code K0825). 
 
You asked the Plan to pre-approve the DME. You say that power mobility would enable the member to better 
integrate into the facility and gain back their sense of autonomy, which is so important to the member. You 
state the member does consider this facility to be their home and would like to enjoy it to the fullest extent.  The 
Plan denied your request. The Plan says the Medicare benefit policy manual states a long term care facility is 
not considered a home and a wheelchair and/or accessories cannot be reimbursed separately as it is included in 
the facility per diem billed rate. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the DME is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair, group 2 heavy duty, captains chair, patient weight 
capacity 301 to 450 pounds (CPT Code K0825).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion interspinous spacer (22869, 22870). 
 
You asked the Plan to pre-approve the spinal surgery. You say that the insertion of a lumbar interspinous 
spacer would provide significant clinical and quality of life benefits. This treatment is medically necessary and 
appropriate for this stage of the disease progression. The Plan denied your request. The Plan says this service is 
considered experimental and investigational and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve Vertiflex superion interspinous spacer (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
7, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says laboratory results have not been submitted for the date of service. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no provider records have been submitted for review. Therefore, there is no evidence of a provider's 
specific concern for drug abuse or misuse.  The UDS and UDT appear to have been ordered simultaneously. 
There is no evidence that UDS results were reviewed prior to ordering the UDT. The UDT is not shown to have 
been tailored to the enrollee's addictions, medications or UDS results. Therefore, the documentation does not 
support that the provided UDS and confirmatory UDT were 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on November 7, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on July 8, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a screening 
colonoscopy. The Plan denied your request. The Plan says this was a medical colonoscopy and you were 
charged the 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 $400 
copayment for outpatient surgery.  
 
You have been asked to pay a $400 copayment for the colonoscopy. The screening colonoscopy became a 
diagnostic colonoscopy. The colonoscopy falls within the outpatient surgery benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  
 
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on 
July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, G0481) provided on March 
30, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were time-sensitive 
and medically necessary. 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 laboratory services (80307, G0481) provided 
on March 30, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the 
periapical x-ray (D0220) provided on July 9, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you had bitewing x-rays done on the 
date of service. You say that the wrong code was billed. You say that you paid for the services when you 
received them. You also say that you are covered for bitewing x-rays with a $0 copayment. The Plan denied 
your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says periapical 
x-ray is not listed as a covered service either. 
 
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 services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee's wheelchair was left at her 
previous residence. The Plan denied your request. The Plan says the reasonable lifetime requirement has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage. Replacement of equipment due to 
irreparable wear takes into consideration the reasonable useful lifetime of the equipment. The reasonable useful 
lifetime cannot be less than 5 years.   
 
We looked at the file and Medicare rules. The record shows that the enrollee previously received a manual 
wheelchair in 2017. The submitted medical records do not include documentation of loss or irreparable damage 
and the reasonable useful lifetime has not been met. Based on this information, we decided that Medicare rules 
 
 
for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve superion interspinous spacer. 
 
You asked the Plan to pre-approve superion interspinous spacer. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has spinal stenosis. The requested spacer is considered 
experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of superion interspinous spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve superion interspinous spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services (97124). 
 
You asked the Plan to pre-approve the massage therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's benefit for massage therapy has been 
exhausted. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The plan 
provides supplemental coverage for up to 10 massage therapy visits. The record shows this benefit has been 
exhausted at this time. Therefore, we decided that the Plan does not have to pre-approve massage therapy 
services (97124).