Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a focused ultrasound of the head. 
 
You asked the Plan to pre-approve the ultrasound. You say that you have Parkinson's and the requested 
treatment is medically necessary. The Plan denied your request. The Plan says the coverage for the requested 
procedure is limited to patients who have an essential tremor only. 
 
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 ultrasound. Our reviewer says that 
the requested ultrasound is not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are seeking treatment of the tremor in your non-dominant hand. Furthermore, based on the 
records provided, you carry a diagnosis of idiopathic Parkinson's Disease (moreso than a stand-alone diagnosis 
of essential tremor). The guidelines do not readily provide coverage of the requested service in people with 
Parkinson's disease. The current medical literature does not well define the role of this requested service in 
Parkinson's. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a focused ultrasound of the head.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213) provided by an out of network 
(OON) provider. 
 
You asked the Plan to pay for OON office visits. You say that the enrollee said he was covered under 
Medicare. The Plan denied your request. The Plan says these 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 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 office visits (99213) provided by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) scan of the brain 
stem and the laboratory service (82565) rendered by the out of network (OON) provider on July 13, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider without 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 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 magnetic resonance imaging (MRI) scan of the brain stem and the laboratory 
service (82565) rendered by the out of network (OON) provider on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, and a power tilt seating 
system. 
 
You asked the Plan to pre-approve the requested services. You say that the tilt does not come standard and is 
needed for pressure relief. The Plan denied your request. The Plan says the enrollee is already approved for a 
tilt and recline feature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
We looked at the file and the rules. The requested power seat elevation system does not serve a purpose that is 
primarily medical in nature. The requested tilt feature is included in the already approved in the tilt and recline 
seating system. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, and a power 
tilt seating system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve complete 
denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit, includes a personalized prevention 
plan of service (G0439) provided July 16, 2020. 
 
You asked the Plan to pay for the annual wellness visit. You say that you had called the plan and was told that 
this doctor was in-network. You still don't understand what happened but was told this can be taken care of. 
The Plan denied your request. The Plan says the maximum benefit has been exhausted. 
 
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 the plan allows 
coverage for one routine physical exam each calendar year. This service is covered under the plan benefits. The 
plan has already paid for one annual wellness visit for the 2020 year for date of service February 28, 2020. 
Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not 
been met. Therefore, we decided that the Plan does not have to pay for annual wellness visit, includes a 
personalized prevention plan of service (G0439) provided July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the outpatient diagnostic testing. You say that you would like reconsideration 
because you were not informed that this doctor was not in-network. The Plan denied your request. The Plan 
says medically necessary care is available in-network. 
 
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 4, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up ventilator (CPT Code E0465) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the requested item is a duplicate item, therefore, not covered by Medicare. 
 
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 services have not been met. A back up ventilator is not a 
covered benefit. Furthermore, the member does not have out-of-network benefits. Therefore, we decided that 
 the Plan does not have to pre-approve a back-up ventilator (CPT Code E0465) to be provided by an out-of-
network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on May 2, 
2020. 
 
You asked the Plan to pay for home health services. 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 payable. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
 
 
was billed with type of bill 321, which is not payable. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee on May 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests (81261, 81264, 88381, G0452) provided on 
January 2, 2019. 
 
You asked the Plan to pay for laboratory tests. You say that this claim was originally filed timely. The Plan 
denied your request. The Plan says this claim was filled outside of the required time frame. 
 
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 laboratory tests was not filed until July 13, 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 laboratory tests (81261, 81264, 88381, G0452) provided on January 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L300 GO functional electrical stimulator. 
 
You asked the Plan to pre-approve the L300 GO functional electrical stimulator. You say that you would like 
reconsideration because this equipment is medically necessary to maximize the member's ambulatory recovery. 
The Plan denied your request. The Plan says the member does not have a spinal cord injury with paraplegia. 
 
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 L300 GO functional electrical 
stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not reveal that the patient has 
disuse atrophy from a non-neurological cause or needs this device for walking due to a spinal cord injury. 
 
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 L300 GO functional electrical stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the L300 GO functional electrical stimulator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed (93306) and electrocardiogram, 
routine ECG with at least 12 leads (93000) provided July 13, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing the 
amount of the cost share of $114.70 The Plan denied your request. The Plan says this claim was processed and 
the correct copayments were 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 $25 
copayment for Medicare covered non-radiological diagnostic services and $100 copayment for each Medicare 
covered diagnostic service, not including X-rays, performed in a physician?s office or at a free-standing facility 
(such as a radiology center or medical clinic).  
 
You have been asked to pay $114.70 copayment for the diagnostic services. For the EKG the allowed amount 
of $14.70 is lower that the copayment amount of $25. The diagnostic services fals 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 echocardiography, transthoracic, 
real-time with image documentation (2D), includes M-mode recording, when performed (93306) and 
electrocardiogram, routine ECG with at least 12 leads (93000) provided July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. The Plan denied your 
request. The Plan says these services are allowed one time every 60 months. The Plan also says that you 
received these services less than 60 months ago. 
 
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, dentures and are limited to 1 complete 
or partial denture every 5 years. The record shows that you received a complete maxillary denture and a 
complete mandibular denture on June 23, 2020, and your dentures benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular 
denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from May 18, 2020, to 
May 19, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient hospital care was medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says they are not obligated to 
provide payment for unauthorized post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer 
says that the inpatient hospital care was not medically reasonable or necessary. Our physician reviewer found 
the review has determined that the treating physician  did not document (in the physician notes, on a form, or in 
an order) that the patient was not stable for transfer on any dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from May 18, 2020, to May 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on December 24, 2019. 
 
You asked the Plan to pay for an x-ray. You say that this should be covered. The Plan denied your request. The 
Plan says no medical records have been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. No medical records for the service at issue have been submitted. 
Without this information, it cannot be determined if coverage criteria have been met. Based on this 
information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided 
that the Plan does not have to pay for an x-ray (71045) provided on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided by an out of 
network provider. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says you did not request 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 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, while a member of the plan, the member must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available, 
out-of-area dialysis services and cases in which the plan authorizes the use of out-of-network providers. If you 
choose a PCP that is part of an independent practice association (IPA) or medical group, the specialists, 
ancillary providers, and hospitals available to you may be limited to only those contracted with the PCP?s IPA 
or medical group. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 24, 2020, to 
July 23, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
elected hospice on June 22, 2020. The Plan also says that during this time period, necessary skilled nursing 
services would be covered under the enrollee's hospice benefit, not Medicare Part C. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing services provided from June 24, 2020, to 
July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that these 
services meet the medical criteria as established by the Plan for receiving these supplemental benefits. The Plan 
denied your request. The Plan says you do not meet the criteria established to receive the special supplemental 
benefits for the chronically ill. 
 
The rules say that Medicare does not normally cover these supplemental benefits. However, the Plan offers a 
benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan 
covers supplemental benefits for the chronically ill only if you have been diagnosed by a qualified provider 
with certain chronic conditions and meet certain criteria. 
 
We looked at the file and Medicare rules. Although your provider has indicated that you do have some medical 
diagnoses which qualify for coverage, they also indicated that you do not have a high risk for hospitalizations 
and do not require intense care coordination. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefits for the chronically ill have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the special supplemental benefits for the chronically ill.