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

We decided that the Plan does not have to waive the copayment for the ultrasound, complete examination of 
breast including axilla, unilateral (76641) provided June 26, 2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you feel that the service 
should be covered and the copayment should be waived. Why do you have to pay the copay if it was medically 
necessary. The Plan denied your request. The Plan says the claim processed with the correct copayment applied 
per the plan's Evidence of Coverage. 
 
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 $325 per 
day for Medical covered diagnostic radiology services ($100 ultrasound).  
 
You have been asked to pay $85.54 for the breast ultrasound.  The allowed amount was less that the copayment 
amount of $100 per day. Therefore, the lesser amount of $85.54 applies. The breast ultrasound 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 copayment for the ultrasound, complete examination of breast including axilla, unilateral (76641) 
provided June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services at in-network benefit exception for an out-of-network provider.You asked the Plan to pre-approvethe medical services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says there are in-network providers that can provide the services.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 request for a pre-service in-network exception for an out-of-network provider specialist in Family Medicine. You were offered a 60-day transition period to find an in-network physician. There are 167 in-network Family Medicine Physicians in your geographic area. You are a PPO member who would have to see this provider using your out-of-network benefits as explained in your EOC, as there are in-network providers in the region with no evidence that in-network specialist resources in the same geography to you have been exhausted. Thereare also tertiary in-network specialist options available, as well as out of state university options that are in-network. Therefore, no in-network inadequacies are seen. The Plan approved a transition period effective August 25, 2020, through October 24,2020.Therefore, we decided that the Plan does not have to pre-approvethe medical services at in-network benefit exception for an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve 4 additional physical therapy visits. You say that you want to continue 
physical therapy until you regain your muscle strength. You say that you wish to get to a state where you can 
continue an exercise routine on your own. The Plan denied your request. The Plan says additional visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for this condition 
and additional visits have already been authorized to review an independent exercise program. Our reviewer 
says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing 
treatment. 
 
  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
August 6, 2019. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that  The Plan denied your 
request. The Plan says that you were charged 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 $325 
copayment for Medicare-covered ambulance services per day.  
 
You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls 
within the Medicare-covered ambulance services per day 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 ambulance transport provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92014, 92015) provided on 
June 29, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ophthalmological services (92014, 92015) 
provided on June 29, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tissue exam (88305) performed. 
 
You asked the Plan to waive the copayment for a tissue exam. You say that you disagree with the cost of this 
date of service. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each visit for laboratory tests, non-radiological tests, diagnostic tests, flat film X-rays, and 
ultrasounds.  
 
You have been asked to pay a $20 copayment for a tissue exam. A tissue exam 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 
copayment for a tissue exam (88305) performed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records support the request for 
reprocessing this claim. 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 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 office visit and neurology services with the provider on 
March 10, 2020. 
 
You asked the Plan to pay for office visit. You say that you were not aware this provider had opted out of 
Medicare. The Plan denied your request. The Plan says they confirmed the provider in this case does not accept 
Medicare assignment and has signed an agreement to be excluded from the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
office visit and neurology services with the provider on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe outpatient surgical services rendered on January 20, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you were advised that the copayment would be $295.The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for each surgical or observation room service you get at an outpatient hospital. Review of the file shows that you received outpatient surgical services on January 20, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the surgical or observation room service you get at an outpatient hospital 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 forthe outpatient surgical services rendered on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture for the treatment of chronic (continuing) 
migraines. 
 
You asked the Plan to pre-approve the services. You say that you want acupuncture because you do not want to 
do Botox if you can try something else for your headaches. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back 
pain under certain circumstances and acupuncture for all other conditions is non-covered. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture for the treatment of chronic (continuing) 
migraines.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean electronic connection for a power wheelchair.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has adequate right upper limb strength and function to be able to control the power option using its own switch which is included in the allowance of this power options.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you need to operate 3 or more powered seating actuators through the drive control. Your right upper extremity strength and function are sufficient for you to control any power options through their own individual switches.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 Plandoes not haveto pre-approvean electronic connection for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveall lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT Code L5986) and all lower extremity prosthesis, shank foot system with vertical loading pylon (L5987). You asked the Plan to pre-approvethe services. You say that the items are necessary.The Plan denied your request. The Plansays the items are not 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of damage or problems with current foot requiring repair or replacement. The review indicates that the physician and prosthetist's notes do not document need for new foot. Member's current foot is a K3 foot. Current foot is 2 years old and in good condition. There is no documented physiologic change requiring new prosthetic foot; no irreparable change to the foot is documented; no documentation of repairs for the feet is documented. Requested foot is also K3. The request for a new K3 foot exceeds member's functional need and does not meet the Medicare criteria of reasonable and necessary. The review has determined that the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approveall lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT Code L5986) and all lower extremity prosthesis, shank foot system with vertical loading pylon (L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPT Code 64493, 64494 and 64495.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are not necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer
found there are multiple other probable pain generators and therefore, the request does not meet the criteria of
the LCD. Therefore, the request is deemed not medically reasonable or necessary 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve CPT Code 64493, 64494 and 64495.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic mattress. 
 
You asked the Plan to pre-approve the orthopedic mattress. You say that the mattress is necessary. The Plan 
denied your request. The Plan says this item is not covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthopedic mattress have not been met. This type of orthopedic 
mattress is not covered by Medicare, in addition to no medical evidence of risk in the member's life. Therefore, 
we decided that the Plan does not have to pre-approve the orthopedic mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Superion interspinous spacer (Vertiflex device) (CPT Code 22869).You asked the Plan to pre-approvethe device. You say that the device is necessary.The Plan denied your request. The Plan says this device is considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show the safety and efficacy of the device. It is not the care standard.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion interspinous spacer (Vertiflex device) (CPT Code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (DME) as defined by codes L3670 and L3809 provided to the enrollee on April 16, 2020.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plandenied 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay forthe durable medical equipment (DME) as defined by codes L3670 and L3809 provided to the enrollee on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on March 2, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you've never had to pay for this 
visit before. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for physician/practitioner services/in-network/primary care.  
 
You have been asked to pay a $10 copayment for an office visit. The correct copayment has been applied to the 
office visit that was provided. An office visit falls within the physician/practitioner services/in-network/primary 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided by a 
participating provider on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite and posterior resin-based 
composite provided on June 20, 2020 by an OON provider. 
 
You asked the Plan to pay for the resin-based composites. You say that this provider has been your dentist for 
over 20 years. You also say that this provider is in-network. The Plan denied your request. The Plan says these 
services were rendered by a non-participating provider. The Plan also says that there is no authorization on file 
for these services. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the anterior 
resin-based composite and posterior resin-based composite provided on June 20, 2020 by an OON provider.