Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on July 29, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you never saw your doctor on 
this day. 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 $15 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $15 copayment for physical therapy. The correct copayment has been applied to 
the services that were provided. Physical therapy falls within the outpatient rehabilitation 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 physical therapy provided by a participating 
provider on July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abscess drainage (10061) provided June 3, 2020. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed amount exceeds the allowed amount for a single date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 10061 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, 
we decided that the Plan does not have to pay for an abscess drainage (10061) provided June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on June 22, 2020. 
 
You asked the Plan to waive the copayment. You say that you thought the copayment would be waived. The 
Plan denied your request. The Plan says you are responsible for the copayment. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service.  
 
Review of the file shows that you were provided an ultrasound on June 22, 2020. Per your contract with plan 
name, there is a $160 copayment for an ultrasound. This cost sharing is a contractual obligation that you agreed 
to pay when you enrolled in plan name. However, the Medicare allowed amount for these services was $55.86. 
Given that the allowed amount was less than the $160 copayment, you have been asked to pay $55.86 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound you had on June 
22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided. 
 
You asked the Plan to pay for the dental service. You say that your plan covers 2 prophylaxis. You say that you 
have received 2 prophylaxes at this office. You say that you have not received any of these benefits that you 
had been told you would receive. You also say that you were advised by a plan representative that you have 
insurance for preventive dental benefits. The Plan denied your request. The Plan says that periodontal 
maintenance is not a covered service. The Plan says that periodontal maintenance not considered a routine 
dental cleaning. The Plan says that this is because the cleaning takes place below the gum line. The Plan also 
says that the periodontal maintenance was not denied due to the provider's network status. 
 
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, periodontal maintenance is specifically 
not among those covered under this benefit. The Evidence of Coverage specifically says that periodontal 
cleanings are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an LDCT scan (G0297) performed on July 14, 2020. 
 
You asked the Plan to pay for an LDCT scan. You say that the enrollee's medical condition proved the medical 
necessity for this service. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that LDCT scans are covered as an additional 
preventive service benefit only if all the eligibility criteria are met, including that the enrollee is a current 
smoker or one who has quit smoking within the last 15 years.  
 
We looked at the file and Medicare rules. The case record does not establish that the enrollee is a current 
smoker or one who has quit smoking within the last 15 years. Based on this information, we decided that 
Medicare rules for coverage of a low-dose CT scan have not been met. Therefore, we decided that the Plan 
does not have to pay for an LDCT scan (G0297) performed on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new wheelchair with power tilt for the enrollee. 
 
You asked the Plan to pre-approve the power tilt. You say that this is medically necessary. The Plan denied 
your request. The Plan says wheelchair repair without addition of power tilt can be covered. 
 
 
 
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 power tilt. Our reviewer says that 
the requested power tilt is  not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not need the power tilt to be repaired. The documentation does not indicate a 
high risk of development of a pressure ulcer. The documentation does not indicate an inability to perform a 
weight shift. The documentation does not indicate the enrollee utilizes intermittent catheterization for bladder 
management or requires a power seating system  to manage increased tone or spasticity. 
 
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 power tilt have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new wheelchair with power tilt for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device and oxygen concentrator 
provided from August 20, 2019 to December 20, 2019. 
 
You asked the Plan to pay for the respiratory assist device and oxygen concentrator. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says required information is 
missing. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the respiratory assist device and oxygen 
concentrator provided from August 20, 2019 to December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you constantly fall and would like something 
to secure you while showering. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that this is to keep you from falling in the bathroom. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 27, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until July 30, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on May 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by on August 4, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this item to shower. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) any 
joint of lower extremity (73721) provided August 4, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are not able to pay because you 
have other bills that you already have to pay monthly to live and survive. The Plan denied your request. The 
Plan says the claim was processed with the correct copayment applied per the 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 $150 
copayment for Medicare covered diagnostic radiology services, not including x-rays. $0 copayment for 
mammography and ultrasounds. $150 copayment for all other diagnostic and nuclear medicine radiological 
services.  
 
You have been asked to pay $124.13 for the MRI. The allowed amount was less than the copayment amount of 
$150. The MRI 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 magnetic resonance imaging (MRI) any joint of 
lower extremity (73721) provided August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 30, 2020, by an OON 
provider. 
 
You asked the Plan to pay for an ultrasound of lower extremity. You say that these services were medically 
necessary. 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 June 30, 2020, 
by an OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services received on April 3, 2020. 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
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. Review of the file shows that there was no claim submitted for review with the 
case file. In addition, the documentation does not support that the services were received by an out of network 
provider. The documentation does not support that you were advised that these services are not a covered 
benefit before receiving them.  Also, the Local Coverage Article that is referenced by the plan was retired 
before this date of service. Consequently, the Local Coverage Article cannot be used to support a decision. 
Therefore, we decided that the Plan has to pay for the laboratory services received on April 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a critical access hospital (CAH) swing bed for skilled 
nursing level of care. 
 
You asked the Plan to pre-approve the services. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
 
 
 
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 a critical access hospital (CAH) swing bed for skilled nursing level of care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for knee and hip x-rays rendered on July 3, 
2020. 
 
You asked the Plan to waive the deductible for these services. You say that you should not be charged for the 
x-rays. The Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 $500 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the x-rays benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for 
your covered medical services. This cost sharing is a contractual obligation that had not been met at the time 
these services were received on July 3, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for knee and hip x-rays rendered on July 3, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
May 19, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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, we have confirmed that code 99285 
for the emergency department visit has a bundled relationship with code 99284 and cannot be paid as billed. 
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit 
coded 99285 provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88342) provided on February 27, 
2020. 
 
You asked the Plan to pay for pathology services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available that could perform the services at 
issue. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the pathology services (88342) provided on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the vedolizumab and normal saline 
solution administered on June 4, 2020. 
 
You asked the Plan to waive the coinsurance for these services. The Plan denied your request. The Plan says 
that you were not aware how much this would cost. 
 
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 Medicare-covered Part B drugs.  
 
You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-
covered Part B drugs 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 
vedolizumab and normal saline solution administered on June 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance on April 23, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 23, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 10, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the enrollee wants to see this provider and 
the Plan should pay this claim. The Plan denied your request. The Plan says you did not receive 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on August 10, 2020 by an out of network 
provider.