Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 units of neuropsychological testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says no prior psychological or psychiatric examination has been performed. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there has been so psychiatrist evaluation or diagnostic evaluation. There are no family concerns, and the 
enrollee has family support. 
 
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 pre-approve 30 units of neuropsychological testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on March 25, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you went to the doctor 
because you weren't feeling good that day. You say that you were charged $65 but the doctor didn?t check on 
you or communicate with you. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for each covered urgently needed service. 
 
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the 
"Urgently needed services" benefit category. The records show that you were examined, prescribed medication 
and advised to go to a testing center. 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 urgent care visit 
provided on March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI of the chest spine and MRI of the lumbar provided 
on March 21, 2020 by an OON provider. 
 
You asked the Plan to pay for the MRI of the chest spine and MRI of the lumbar. You say that the enrollee 
provided incorrect information. You also say that these services were medically necessary. The Plan denied 
your request. The Plan says these services were rendered by a non-participating provider. The Plan also says 
that prior authorization was not obtained. 
 
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 MRI of the chest spine and MRI of the lumbar 
provided on March 21, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the sedative filling (D2940) provided on July 23, 
2019. 
 
You asked the Plan to reimburse you for the dental service. You say that x-rays were never required for past 
claims. You also say that the claim should be processed without further paperwork. The Plan denied your 
request. The Plan says x-rays from within 6 months prior to the receiving the service are required to determine 
if the service was eligible for coverage. The Plan says that without the x-rays eligibility cannot be determined. 
 
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 reimburse you for 
the sedative filling (D2940) provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 2, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the enrollee on 
April 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140) of teeth # 29 and 30 provided on 
May 15, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You also say that you 
were advised by a plan representative that you could see an out of network dentist. The Plan denied your 
request. The Plan says the extraction is not specifically listed as 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 requested items or services are not 
among those covered under this benefit. Additionally, the record shows that the Plan paid for the x-ray from the 
same provider on the same date of service. Therefore, we decided that the Plan does not have to pay for the 
extractions (D7140) of teeth # 29 and 30 provided on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial maxillary denture (D5820) and an 
interim partial mandibular denture (D5821). 
 
You asked the Plan to pre-approve the interim partial maxillary denture and interim partial mandibular denture. 
You say that you need these dentures to replace your missing teeth. The Plan denied your request. The Plan 
says these services are not covered. 
 
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 an 
interim partial maxillary denture (D5820) and an interim partial mandibular denture (D5821).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
January 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the services rendered were 
medically necessary The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) 
provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided on December 9, 
2019. 
 
You asked the Plan to waive the copayment for inpatient services. You say that the copayment was supposed to 
be covered by the supplemental part. You say that you cannot afford the copayment. The Plan denied your 
request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $395 
copayment each day for days 1 to 4 for Medicare-covered hospital care. 
 
You have been asked to pay $395 copayment for the inpatient services. Inpatient services fall within the 
"Inpatient Hospital 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 inpatient 
services provided on December 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 units of neuropsychological testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical justification for this. 
 
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 testing. 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 show an evaluation by a psychologist or psychiatrist. There is no diagnostic 
evaluation. 
 
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 pre-approve 25 units of neuropsychological testing for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on October 3, 2018. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you checked 
that the procedure would be covered 100%. You say that you are unable to cover this expense. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Medicare-covered outpatient diagnostic radiology services.  
 
You have been asked to pay a $300 copayment for the myocardial perfusion imaging. The myocardial 
perfusion imaging 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 myocardial perfusion imaging provided on 
October 3, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the temperature gradient studies (93740) provided on July 
15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for temperature gradient study. You say that the services rendered are not provided 
in-network. The Plan denied your request. The Plan says a written referral must be approved by the Plan's 
medical director prior to seeking care from an out-of-network provider. 
 
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 temperature gradient studies (93740) provided 
on July 15, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on March 27, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this surgery only happened 
because of a doctor's mistake. 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 $150 
copayment for outpatient surgery.  
 
You have been asked to pay a $150 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery 
provided by a participating provider on March 27, 2020.  
 
We note your complaint about needing this surgery due to a doctor?s error. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve indefinite continuity of care to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve continuity of care. You say that you believe that continuity of care is vital as 
this provider has been the physician who operated on your lumbar spine on 3 occasions. It will be extremely 
difficult to start with a new neurosurgeon. The Plan denied your request. The Plan says enrollee's must receive 
their medical services from an in-network provider. If an enrollee requires medical care that Medicare requires 
the plan to cover and there are no network providers who can provide the care, then the enrollee can receive the 
care from an out of network provider.   
 
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 
indefinite continuity of care 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 pre-approve skin substitute wound care services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has been improving with traditional wound therapy. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic venous hypertension with a non-healing ulcer. The review has 
determined that the requested wound care is not medically reasonable or necessary over the standard of care, as 
the documentation demonstrates improvement with traditional therapy. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute wound care services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the minimally invasive implantation is 
the most appropriate treatment for the enrollee. The Plan denied your request. The Plan says the requested 
service is not identified as widely used and generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the requested device is considered experimental. More research is needed to show the 
device's safety and efficacy. Therefore, the requested service is not medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick external catheter. 
 
You asked the Plan to pre-approve a PureWick external catheter. You say that it is expensive to pay for these 
supplies out-of-pocket. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that female external urinary collection devices are 
covered for beneficiaries who have permanent urinary incontinence when used as an alternative to an 
indwelling catheter. 
 
We looked at the file and Medicare rules. The submitted medical records do not show the item at issue is being 
requested as an alternative to an indwelling catheter. Based on this information, we decided that Medicare rules 
for coverage of a PureWick external catheter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PureWick external catheter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you are requesting 
continued therapy or at least 2 visits. 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 10 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 the enrollee received 50 therapy 
treatments and strength and range of motion appear to be within normal range. Our reviewer says that 
additional therapy treatments are not likely to provide any further benefit. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT head or brain. 
 
You asked the Plan to pre-approve Computed tomography, head or brain; without contrast material (70450). 
You say that a CT head/brain is not medically necessary. The Plan denied your request. The Plan says a CT of 
the head or brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 Computed tomography, head or brain; 
without contrast material (70450). Our reviewer says that the CT is not medically necessary. Our physician 
reviewer found the documentation does not support the need for repeat head CT. The test was initially 
performed on July 20, 2020. More info is needed to justify the reason for the repeat head CT. It is not clinically 
indicated at this time based on the available medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Computed tomography, head or brain; without contrast material (70450) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a CT head or brain.