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

 
We decided that the Plan does not have to pre-approve a zoom auto flex folding travel mobility scooter for the 
enrollee. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information does not indicate that the current scooter does not meet needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the available 
documentation does not support that the enrollee in this case requires this specific new scooter. The 
documentation does not support that the power scooter provided to the enrollee is insufficient for her needs. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a zoom auto flex folding travel mobility scooter for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI services provided on February 12, 
2020. 
 
You asked the Plan to waive the deductible for the MRI services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received MRI services on the date of service at issue in this appeal. The Plan 
says that the correct amount has applied towards your deductible per your contract with the Plan. 
 
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 $198 deductible that must be paid before the Plan will pay their share 
for Outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 
deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests. This cost 
sharing is a contractual obligation that had not been met at the time the MRI services were received on 
February 12, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the MRI 
services provided on February 12, 2020.
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 the services can be received in another setting, such as a skilled nursing facility. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a femur fracture. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on July 29, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you believed fluoride 
treatment was a covered benefit. The Plan denied your request. The Plan says the service requested is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
topical application of fluoride varnish (D1206) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 25, 2020. 
 
You asked the Plan to pay for the dental service. You say that your appointment was scheduled for August 25, 
2020. You say that you kept the appointment so that you could stay on your 3 month schedule. You say that the 
services should be covered. The Plan denied your request. The Plan says 2 cleanings are covered every plan 
year. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 2 cleanings per 
plan year has been exceeded. The record shows that the Plan paid for cleanings that you received on February 
3, 2020 and June 4, 2020. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) 
provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 1015TCA06 Receiver (monitor) for use with 
therapeutic glucose continuous monitor system. 
 
You asked the Plan to pre-approve a 1015TCA06 Receiver (monitor). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, and require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of a 1015TCA06 Receiver (monitor) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a 1015TCA06 Receiver (monitor) for use with therapeutic 
glucose continuous monitor system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit received on September 18, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you disagree with the amount 
owed. The Plan denied your request. The Plan says the claim has been processed correctly per your 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 a $30 
copayment for physician/practitioner services.  
 
Review of the file shows that your copayment requirement is $30. However, the allowed amount for this 
service was $23.67. Since this is less than your copayment requirement, you were charged the lesser amount. 
While you might have only had Covid-19 testing. However, the documentation shows that the purpose of this 
visit was for a pre-procedural examination and you also had Covid-19 testing which was sent to an outside 
laboratory for processing.  
 
You have been asked to pay a $23.67 copayment for the office visit. The office visit falls within the 
physician/practitioner 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 copayment for 
the office visit received on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these 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 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 
an office visit (99205) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 70547 and CPT 70551) provided to 
the enrollee. 
 
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 the claim did not include the appropriate primary, first-listed or principal diagnosis. 
 
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 the denied codes is: 
 
CPT 70547: 
 
Magnetic resonance angiography, neck 
 
CPT 70551: 
 
Magnetic resonance (eg, proton) imaging, brain (including brain stem) 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted was reviewed, and it does not meet the criteria. Per the ICD-10 guidelines, "Code 
first underlying cerebrovascular disease (I60- I69)", therefore, it is inappropriate to bill a service with a 
secondary diagnosis code. 
 
 
 
 
 
 
 
 
 
 
 
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 radiology services (CPT 70547 and CPT 70551) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740), core buildup 
(D2950), and gingivectomy or gingivoplasty for restorative procedure (D4212). 
 
You asked the Plan to pre-approve the porcelain/ceramic crown, core buildup, and gingivectomy or 
gingivoplasty for restorative procedure. You say that these services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says these services are not covered by the Plan. 
 
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 the 
porcelain/ceramic crown (D2740), core buildup (D2950), and gingivectomy or gingivoplasty for restorative 
procedure (D4212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from January 
11, 2020, to July 11, 2020. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that there is no justification for 
you to be billed these amounts. The Plan denied your request. The Plan says the coinsurance amounts you are 
being charged are correct. 
 
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 in-network oxygen equipment and supplies. The allowed amounts of these claims total 
$2,039.16, resulting in a total coinsurance obligation of $407.84. 
 
You have been asked to pay 20% coinsurance for oxygen equipment. Oxygen equipment falls within the 
Durable Medical Equipment (DME) and Related 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 coinsurance for oxygen equipment provided from January 11, 2020, to July 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out of area elective surgery and inpatient services 
provided from July 5, 2019 to July 7, 2019. 
 
You asked the Plan to pay for the out of area services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out of area care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that the out of area services were not due to an 
unforeseen illness or condition. The services were not pre-approved. Based on this information, we decided 
that Medicare rules for coverage of the out of area services have not been met. Therefore, we decided that the 
Plan does not have to pay for the out of area elective surgery and inpatient services provided from July 5, 2019 
to July 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the acupuncture services. You say that you have used this provider before, and they 
are more convenient than the plan provider. The Plan denied your request. The Plan says there are Plan acupuncture 
providers available to you.  Furthermore, the Plan states that the requested provider does not meet Medicare requirements 
in order to treat Medicare members. 
 
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. In addition, the requested provider does not meet Medicare 
coverage criteria in order to provide acupuncture services to Medicare patients. 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 the 
acupuncture to be provided 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 medical services provided on January 1, 2020 to January 2, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you believed authorization was in place for these 
services. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan has 
confirmed that neither the provider of service nor the facility where the services occurred is a contract provider with the 
Plan.  The services of both the provider of service in this case and the facility were unauthorized by 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 provider in this case is not a network provider with the Plan. 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 January 1, 2020 to January 2, 2020 by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 17, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by the provider. The provider is a contract provider. The 
file does not show that the plan provided notice that the laboratory services would not be covered. Under 
Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on June 17, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional non-emergent transportation trips. 
 
You asked the Plan to provide coverage for an additional non-emergent transportation trips. The Plan denied 
your request. The Plan says the member has exhausted the benefits for the calendar year. 
 
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 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 
all of the 24 one-way trips for the 2020 calendar year. Based on this information, we decided that the enrollee 
has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to provide coverage for additional non-emergent transportation trips.