Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, periodic oral evaluation, and 
periodontal maintenance provided on June 8, 2020. 
 
You asked the Plan to pay for the preventive procedure, periodic oral evaluation, and periodontal maintenance. 
You say that you had no choice but to see this provider, because the other dentist was not in on this date of 
service. You also say that you need to be reimbursed because you are on a set income. The Plan denied your 
request. The Plan says these services were rendered by a Medicare opt out provider. The Plan also says that 
services performed by a privately contracted provider are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure, periodic oral evaluation, and periodontal maintenance provided on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says more studies need to be done, and the procedure is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the PILD procedure is considered experimental. More research is needed to show safety and efficacy. 
 
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 percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon May 7, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. This provider is not a network provider with the Plan. We have also determined that these services are not urgent or emergent, nor were they approved in advance.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 Plandid not pre-approve the physician's services.We found no exception that would require the Plan to payfor these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 2, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you cannot afford the charges. 
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 $50 
copayment a specialist visit.  
 
You have been asked to pay the allowed amount of $43.89, which is less than the $50 copayment for a 
specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 
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 specialist visit provided on 
June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physician?s services. 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 physician's services provided on March 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services have been found to be 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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found coverage criteria for split-night polysomnography (PSG) are not met.  The medical records do not 
include a clinical evaluation, with justification of the need for the PSG, results of previous PSGs and 
treatments, and focused examination. Therefore the PSG is considered not medically 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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 16, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says prior 
authorization was obtained by the provider or the facility. 
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on July 16, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on November 19, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for diagnostic radiology services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 
for these services. The Plan says that the member's primary care physician did not referring these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 diagnostic radiology services provided on 
November 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on November 1, 2019 and billed under code 80307.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says there were insufficient medical records, physician orders and/or lab orders submitted for payment of this claim.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 records provided do not support the services billed. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on November 1, 2019 and billed under code 80307.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an additional 2 months rental of the tumor treatment field therapy 
device. 
 
You asked the Plan to pre-approve an additional 3 months rental of the Optune device (E0766). You say that 
the enrollee needs continuation of the device rental. The Plan denied your request. The Plan says that the report 
indicated only 75% compliance, but they will approve 1-month additional rental to encourage compliance. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 additional 2 months rental of the 
Optune device (E0766). Our reviewer says that the requested items are considered medically reasonable and 
necessary in this case. Our physician reviewer found criteria is met for continuation. The enrollee has stable 
disease and used TTF 18/24 hours or 75%. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional 2 months rental of the Optune device (E0766) have been met. 
Therefore, we decided that the Plan has to pre-approve an additional 2 months rental of the tumor treatment 
field therapy device.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was diagnosed with 
obstructive sleep apnea (OSA) from a diagnostic sleep study in November of 2018. CPAP was tried and not 
tolerated, but the medical records provide no details on the nature of the intolerance or what attempts were 
made to address it. The most recent clinical notes are from February of 2019. CPAP was tried and not tolerated, 
but the medical records provide no details on the nature of the intolerance or what attempts were made to 
address it. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays and laboratory services provided 
on June 15, 2020. 
 
You asked the Plan to waive the copayments for X-rays and laboratory services. You say that you received a 
bill from the provider and it shows that you do not owe a copayment. 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 $14 
copayment for X-ray services and a $10 copayment for lab services. 
 
You received X-rays on June 15, 2020. Therefore, you are responsible to pay the $14 copayment.  
 
You received laboratory services on June 15, 2020. Therefore, you are responsible to pay the $10 copayment.  
 
The total amount you owe is: $24.  
 
You have been asked to pay the total copayment amount of $24 for X-rays and laboratory services. X-rays and 
laboratory services fall 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 copayments for X-rays and laboratory services provided on 
June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a 
dermatologist on July 20, 2020. 
 
You asked the Plan to waive the copayment for the dermatology office visit. You say that the medical records 
are not accurate.  You say that this doctor didn't fully examine you. The Plan denied your request. The Plan 
says you were charged this copayment 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 $40 
copayment for visits with a specialist.  
 
You have been asked to pay a $40 copayment for the dermatology office visit. The dermatology office visit 
falls within the visits with a specialist benefit category. This copayment applies regardless of your satisfaction 
with the services. 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 office visit you had with a 
dermatologist on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 16, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you work with participating providers. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that the member's primary care physician did not refer these 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 lab work provided on June 16, 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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you believed that these stockings 
would be covered. The Plan denied your request. The Plan says the requested stockings are a non covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
low back pain radiating to both lower extremities. Current evidence based medical guideline and peer reviewed 
literature do not fully support the requested spinal decompression device procedure over the gold standard of 
lumbar laminectomy. The services are considered experimental in nature and not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel 
resistance walker. 
 
You asked the Plan to pre-approve heavy duty, multiple braking system, variable wheel resistance walker. You 
say that your doctor wants you to have this walker, so it must be medically necessary. The Plan denied your 
request. The Plan says the denial of authorization for this item is correct, because the documentation does not 
show that you are unable to use a standard walker due to a severe neurologic disorder or other condition 
causing the restricted use of one hand. 
 
The Plan follows Medicare rules. Medicare rules say that a heavy duty, multiple braking system, variable wheel 
resistance walker is covered only when the above clinical criteria have been met.   
 
 
 
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 heavy duty, multiple braking system, 
variable wheel resistance walker. Our reviewer says that you do not meet the Medicare criteria for this walker. 
Our physician reviewer found the documentation does not indicate that you have a mobility limitation that 
impairs participation in mobility-related activities of daily living (MRADLs) in the home. There is no evidence 
that you are unable to use a standard walker due to a severe neurologic disorder or other condition causing the 
restricted use of one hand. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heavy duty, multiple braking system, variable wheel resistance walker have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, multiple braking 
system, variable wheel resistance walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 26, 2020 
 
You asked the Plan to waive the copayment for office visit. You say that the copayment should be waived. The 
Plan denied your request. The Plan says the copayment is correct. 
 
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 $45 
copayment for specialist for Physician/Practitioner Services, Including Doctor?s Office Visits.  
 
You have been asked to pay a $45 copayment for specialist for office visit. This service falls within the 
Physician/Practitioner Services, Including Doctor?s Office Visits 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 office visit provided on March 26, 2020