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

 
We decided that the Plan does not have to pre-approve multiple power options for a wheelchair (E2311, E2377, 
E2313) and a transportation tie down (K0108) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically 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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that there is a medical purpose for the requested 
transportation tie down. The documentation does not support that the coverage criteria for multiple power 
options for a power wheelchair, including E2311, E2377, and E2313 are met in this case. The documentation 
does not support that the enrollee in this case requires both power tilt and power recline features. The upgraded 
controller, harness and electronics is not covered as there is not documentation of a medical need to control 
more than two power options through a joystick. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve multiple power options for a wheelchair (E2311, E2377, E2313) and a transportation tie 
down (K0108) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve this item. You say that a total electric hospital bed is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee. 
 
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 CPT code 70450-26 (Computed tomography, head or brain; without contrast material) 
denied because it is a column II procedure to the column I procedure, 70496-26,GC billed by another provider 
in the same group. Also, CPT code 70450 is the column II code to the more comprehensive column I code of 
70496. The Plan states a modifier is allowed in order to differentiate between the services provided. Per review 
of the submitted documentation, the interpretation of the CT of the head without contrast has a service date  
and time of 8/3/20020 8:29:00PM. The medical records also include the interpretation from another provider 
at the same time. For these services to be paid separately an appropriate modifier is needed to represent the 
services as separate and distinct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the claim submitted is lacking the 
documentation required and the modifier required to show this was a separate and distinct service. Medicare 
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay 
for imaging services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided an out-of-
network provider on June 7, 2019. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you did not know the lab was 
out-of-network. You say that you are appealing for insurance to pay this bill. The Plan denied your request. The 
Plan says the deductible 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 your yearly out-of-network deductible is $250. This is the amount you have to 
pay out-of-pocket before we will pay our share for your covered out-of-network services. Until you have paid 
the deductible amount, you must pay the full cost for most of your out-of-network covered services. 
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $250 deductible applies to out-of-network services. This cost sharing is a 
contractual obligation that had not been met at the time laboratory services were received on June 7, 2019. 
Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided an 
out-of-network provider on June 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the medical services. You say that you are out-of-network with the Plan, so no 
referral was obtained. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 medical services provided on August 10, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor and sensors (A9276, A9278). 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor and sensors. You say that the continuous 
glucose monitor is medically necessary. The Plan denied your request. The Plan says rules for coverage have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Continuous Glucose Monitor is covered when 
the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record does not show that you are treated with insulin injections. 
Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose Monitor 
and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous 
Glucose Monitor and sensors (A9276, A9278).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary and would help 
tremendously. The Plan denied your request. The Plan says this is a non-medical-grade scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that a power scooter is the appropriate DME for you in this case. You walk with a walker, 
ambulating a normal distance of 30 feet. The gait is described as antalgic and labored. On 11/4/20, a Group-2 
power wheelchair was deemed to be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Hyaluronan gel injections (J7326) 
provided on August 4, 2020. 
 
You asked the Plan to waive the coinsurance for the Hyaluronan gel injections. You say that you do not agree 
with the coinsurance as charged. The Plan denied your request. The Plan says the coinsurance has applied 
correctly in this case. 
 
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 Medicare Part B Prescription Drugs.  
 
You have been asked to pay a total cost share of $453.20 ($2266.00 allowed amount x 20%). The service falls 
within the Medicare Part B Prescription 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 Hyaluronan gel injections (J7326) provided on August 4, 2020.  
 
We read your letter and knows that you may have a quality of care concern. We cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a blood typing test provided on June 13, 2020. 
 
You asked the Plan to waive the copayment for a blood typing test. You say that you thought copayments for 
COVID-19 testing were waived. 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 $10 
copayment for laboratory tests. 
 
The record shows that you received a blood typing test on June 13, 2020. Therefore, you are responsible to pay 
the $10 copayment.   
 
You have been asked to pay a $10 copayment for a blood typing test. A blood typing test 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 blood typing test provided on June 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture and complete upper denture. 
 
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. 
 
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 a 
lower partial denture and complete upper denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup teeth 28, 29 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says this service is not covered 
under the plan benefits. 
 
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. Services not listed under the in 
the benefit char is not covered by the plan. 
 
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 core 
buildup teeth 28, 29 (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prosthesis removal and replacement 
provided. 
 
You asked the Plan to waive the coinsurance for the prosthesis removal and replacement. You say that you had 
this procedure done ten years ago and didn't have a bill like this. You say that this was a necessary procedure 
and it is near impossible to finish paying the bill. 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 25% 
coinsurance for each covered surgery or observation room service in an outpatient hospital.  
 
You have been asked to pay $5,322.71, which is 25% of the allowed amount for the prosthesis removal and 
replacement. The allowed amount is $21,290.85 (25% x $21,290.85 = $5,322.71). The prosthesis removal and 
replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" 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 prosthesis removal and replacement provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMedical Nutrition Therapy.You asked the Plan to pre-approvemedical nutrition therapy services. You say that these services are medically necessary.The Plan denied your request. The Plan says this service is covered only for certain enrollees.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pre-approveMedical Nutrition Therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compressor and a segmental pneumatic appliance provided on August 5, 2020.You asked the Plan to pay fora pneumatic compressor and a segmental pneumatic appliance. You say that the records provided support the need for the items in dispute.The Plandenied your request. The Plan says the criteria for coverage have not been met.The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices and appliances are covered when certain medical criteria have been met.We asked ourphysician 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 a pneumatic compressor and a segmental pneumatic appliance. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support that the enrollee has lymphedema with Marked hyperkeratosis with hyperplasia and hyperpigmentation, Papillomatosis cutis lymphostatica,Deformity of elephantiasis, or Skin breakdown with persisting lymphorrhea. The case file does not contain detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. There is insufficient documentation of persistence, with lymphedema that is documented to be unresponsive to other clinical treatment over the course of a required four-week trial.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofa pneumatic compressor and a segmental pneumatic appliance have not been met.Therefore, we decided that the Plan does not have to pay fora pneumatic compressor and a segmental pneumatic appliance provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on September 2, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim needs documentation for reason and location of injury. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records to 
support the services billed. 
 
In this case, there were insufficient records provided to support the claim billed. Medicare billing criteria are 
not met. Therefore, we decided that the Plan does not have to pay for the ambulance service provided on 
September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival irrigation (D4921), topical fluoride treatment 
(D1206), and drugs for home use (D9630) received on August 11 and August 26, 2020. 
 
You asked the Plan to pay for a gingival irrigation, topical fluoride treatment, and drugs for home use. You say 
that these services are covered on your insurance in full. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a gingival 
irrigation (D4921), topical fluoride treatment (D1206), and drugs for home use (D9630) received on August 11 
and August 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only with CPT codes 93010 and 93010-59, 76 provided. 
 
You asked the Plan to pay for the CPT codes 93010 and 93010-59, 76. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code  is Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only. 
 
We find that CPT codes 93010 and 93010-59, 76 are not supported in the medical record. Specifically, there is 
no documentation of interpretation and report of EKG for the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage of the CPT codes 93010 and 93010-59, 76 have not 
been met. 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only with CPT codes 93010 and 93010-59, 76 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contactless thermometer (E1399). 
 
You asked the Plan to pre-approve the thermometer. You say that you were in the ER and was told by staff that 
you have COVID or pneumonia and it is medically necessary. The Plan denied your request. The Plan says this 
item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve contactless thermometer (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the specialist visit provided. 
 
You asked the Plan to waive the co payment for the specialist visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received an office visit in a Specialty Physician's office on the date of service 
at issue in this appeal. The Plan says that the correct co payment has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
co payment for Specialty Physician office visit services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received office visit 
services within a Specialty Physician's office. You have been asked to pay a $20 co payment 
for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the co payment for the specialist visit provided .
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be paid in full. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 medical services provided by 
an OON provider.