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

We decided that the Plan does not have to pre-approve Arthrodesis. 
 
You asked the Plan to pre-approve Arthrodesis, sacroiliac joint (27279). You say that the enrollee needs this 
procedure for pain management. The Plan denied your request. The Plan says the records show the enrollee 
may have another issue causing the pain. 
 
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 Arthrodesis (27279). Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets all of the criteria for an SI joint fusion of the LCD except for not having had 
a CT or MRI of the SI joints.  Because of this one missing item, the request is deemed not medically reasonable 
at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arthrodesis (27279) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arthrodesis.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit for Pain Management at an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an office visit with an OON provider. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says that there are in-network providers 
available to you. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers 
located within reasonable distance and travel time from your home who can provide an office visit for Pain 
Management. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we 
decided that the Plan has to pre-approve an office visit for Pain Management at an out-of-network (OON) 
provider.  
 
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 compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings 
for circulation. The Plan denied your request. The Plan says compression stockings are not covered by 
Medicare for your condition. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on March 2, 
2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that last year your ostomy 
supplies were paid for and now you owe 20%. You say that you want help with the cost. The Plan denied your 
request. The Plan says the coinsurance 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 20% 
coinsurance for prosthetic devices and medical supplies.  
 
You have been asked to pay $49.40, which is 20% of the allowed amount for the ostomy supplies. The allowed 
amount is $247 (20% x $247 = $49.40). The ostomy supplies fall within the "Prosthetic devices 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 the ostomy supplies 
provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT panel provided to the enrollee on October 26, 
2019. 
 
You asked the Plan to pay for the testing. You say that this should have been processed as a medical necessity. 
The Plan denied your request. The Plan says there is insufficient evidence to support both the validity and 
clinical utility of this testing. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited evidence that molecular profiling of tumor tissue can improve health outcomes for 
patients with cancer. To date, this testing is not FDA approved and has not gone through the MolDX Technical 
Assessment process. The review has determined that the enrollee did not meet the criteria for this testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xT panel provided to the enrollee on October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from June 
18, 2020, to July 2, 2020. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you were not aware of what 
they would do. 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 $225 
copayment for outpatient surgery.  
 
You received wound debridement provided from June, 18, 2020, to July 2, 2020, for a total of 3 visits. Wound 
debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 
copayment per each service. The total amount you owe is: $225 (copayment) x 3 (services) = $675.  
 
You have been asked to pay the total copayment amount of $675 for wound debridement. Wound debridement 
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 copayments for 
wound debridement provided from June 18, 2020, to July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair headrest, SynerGel arm pads, and Ability 
Drive. 
 
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 say that a wheelchair headrest cannot be requested under code 
K0108. 
 
We looked at the file and Medicare rules. The file shows that the headrest is being requested with code K0108. 
This is improper coding for this item, and the services must be submitted under code E0955. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The services at issue are SynerGel arm pads described by code K0019. The Plan has approved a power 
wheelchair base described by code K0861. Code K0019 is a column II code with a modifier indicator of 1 
when billed with column I code K0861. The arm rests described by code K0019 therefore cannot be approved 
with code K0861. 
 
The rules say that code E2351 describes an electronic interface used with a speech generating device. 
 
The services at issue are an Ability Drive from TOLT Technologies. The file shows that this item does not 
have FDA-approval. The Plan has approved an electronic interface that can be used with a speech generative 
device under code E2351. 
 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair headrest, SynerGel arm pads, 
and Ability Drive.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 4, 2020, by an OON 
provider. 
 
You asked the Plan to pay for nursing facility care. You say that these medically necessary services were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have 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 the medical services provided on May 4, 2020, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry services provided from May 20, 
2020, to September 3, 2020. 
 
You asked the Plan to waive the copayments for podiatry services. You say that you thought that copayments 
were waived due to the pandemic. 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 $45 
copayment for podiatry services.  
 
You received podiatry services from May 20, 2020, to September 3, 2020, for a total of 7 visits. Podiatry 
services are not included in the copay waiver due to COVID-19. Therefore, you are responsible to pay a $45 
copayment per each visit. The total amount you owe is: $45 (copayment) x 7 (podiatry visits) = $315.  
 
You have been asked to pay the total copayment amount of $315 for podiatry services. Podiatry services fall 
within the podiatry 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 podiatry 
services provided from May 20, 2020, to September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2) provided from June 29, 2020, 
to August 31, 2020. 
 
You asked the Plan to pay for the dental services. You say that you called the Dental Plan and were advised 
that core build up is not covered. You say that you have a lot of dental work that needs to be done. You also 
say that you need core build up or a root canal as advised by your dentist. The Plan denied your request. The 
Plan says core build up is not a covered service. 
 
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 core build up is not among those 
covered under this benefit. Additionally, the record shows that you were advised by a plan representative that 
the service would not be covered. Therefore, we decided that the Plan does not have to pay for the core build 
up (D2950 x 2) provided from June 29, 2020, to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion consultation with an OON provider. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified 
in-network providers available to you that can provide the services you are requesting. 
 
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 
a second opinion consultation to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 19, 2020, by an out-
of-network. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is not in-network and the member was referred by their non-
participating outpatient nursing facility. 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 June 19, 2020, by an out-of-network.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 15, 2020, by an out-
of-network. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the member self-directed to an out-of-network provider, the member's primary care 
physician did not refer for the services and there is no medical necessity. 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 
June 15, 2020, by an out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 8, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this provider is not in-network, the services are not urgent or emergent, and the 
services were not approved in advance. 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 April 8, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an echocardiograph provided on March 
26, 2020. 
 
You asked the Plan to waive the coinsurance for an echocardiograph. You say that you were informed that the 
test would be covered as preventative. 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 20% 
coinsurance for diagnostic procedures and tests. 
 
You received an echocardiograph on March 26, 2020. An echocardiograph is considered a diagnostic 
procedure and is not preventative. Therefore, you are responsible to pay your share of the cost-sharing charges. 
The allowed amount is $77.24 and 20% of that is $15.45.  
 
You have been asked to pay the total coinsurance amount of $15.45 for an echocardiograph. An 
echocardiograph falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
Therefore, we decided that the Plan does not have to waive the coinsurance for an echocardiograph provided 
on March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need this to treat your pain. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need a power wheelchair. The Plan 
denied your request. The Plan says there is no physician order or evaluation for a power wheelchair. 
 
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.  

The file shows that your condition can be improved by a walker, cane or manual wheelchair. The Plan 
requested the physician order but it was not received. There is no face-to-face or home assessment 
documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair.