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

 
We decided that the Plan does not have to pre-approve Q-Logic 3 enhanced display kit (K0108) and figure 8 
bracket with 13" rod and egg switch mount (K0108). 
 
You asked the Plan to pre-approve the wheelchair components. You say that based on the information 
provided, please reconsider the denial for the requested power wheelchair. The Plan denied your request. The 
Plan says K0108, Q-Logic 3 enhanced display kit and K0108, figure 8 bracket with 13" rod and egg switch 
mount are denied as unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The reimbursement for any type of complete expandable controller 
is included in the allowance for codes E2377, E2376 and E2313. The approved controller comes with all 
hardware, switches and other parts needed for it to work properly. These parts cannot be requested separately. 
The approved E2330, includes all related electronics, switch and mounting hardware.  Based on this 
information, we decided that Medicare rules for coverage of the wheelchair components have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Q-Logic 3 enhanced display kit (K0108) and 
figure 8 bracket with 13" rod and egg switch mount (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an LED light kit and fenders. 
 
You asked the Plan to pre-approve an LED light kit and fenders. You say that the items are necessary. The Plan 
denied your request. The Plan says the requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that an electronic interface used to control lights or 
other electrical devices is non-covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an LED light kit and fenders have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an LED light kit and fenders.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myelogram provided on October 25, 
2022. 
 
You asked the Plan to waive the copayment for a myelogram. You say that you do not think that there should 
be a copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for each in-network Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $325 copayment for a myelogram. This item/service falls within the each in-
network Medicare-covered outpatient hospital facility visit 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 myelogram provided on October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on December 27, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you were told that you would not have a 
copay. The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for the x-ray. This item/service 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. However, since the allowed amount is less than the standard copayment, you only owe $77.30. Therefore, we decided that the Plan does not have to waive the copayment 
for the x-ray provided on December 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on June 
09, 2022. 
 
You asked the Plan to waive the copayment for psychotherapy services. You say that you think that the 
copayment for these services should be lower. The Plan denied your request. The Plan says this cost sharing 
was charged 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 out-of-network mental health services provided at a specialists office. 
 
You have been asked to pay a $65 copayment for psychotherapy services. This item/service falls within the 
out-of-network mental health services provided at a specialists office 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 psychotherapy services provided on June 09, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the heart imaging study provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for the heart imaging study. You say that you were not made aware 
of this copayment and feel it is too expensive. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $250 
copayment for outpatient diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for the heart imaging study. This item/service falls within the 
outpatient diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the heart imaging study provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 12, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that these services were medically 
neccesary. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics. 
 
You asked the Plan to pre-approve E2377 x 2, K0108, E2313 x 2, and E2311 x 2 (upgraded electronics). You 
say that the requested power wheelchair is needed as the enrollee is a non-functional ambulator with high fall 
risk. The Plan denied your request. The Plan says the requested toggle switch is already included with the 
requested expandable controller. The Plan also says that the upgraded electronics 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 upgraded electronics. Our reviewer says 
that the requested upgraded electronics are not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee does not have use of the upper extremity and cannot operate and 
control the power options using the switches that are included in the basic wheelchair. Therefore, the reviewer 
found that the requested upgraded electronics are 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 E2377 x 2, K0108, E2313 x 2, and E2311 x 2 (upgraded electronics) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast ultrasound provided on 
November 10, 2022. 
 
You asked the Plan to waive the coinsurance for the breast ultrasound. You say that the facility needs to bill 
this claim with the correct code. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay 20% coinsurance for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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. The total you owe is $20.20 ($100.98 allowed amount x 20% 
coinsurance = $20.20). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
breast ultrasound provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) equipment provided on December 06, 2022. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment. 
You say that you returned this equipment and should not have to make this payment. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous positive airway pressure (CPAP) equipment. 
This item/service falls within the in-network durable medical equipment and related 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 coinsurance for the continuous positive airway pressure (CPAP) equipment 
provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulant management services provided on January 17, 
2023. 
 
You asked the Plan to pay for anticoagulant management services. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anticoagulant 
management services provided on January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the upgraded electronics are 
medically necessary. The Plan denied your request. The Plan says that the upgraded electronics are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the upgraded electronics are medically necessary if it 
is necessary for the enrollee to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the requested electrical 
accessories are not medically necessary as the enrollee does have use of the upper extremities. The enrollee can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring services provided on January 18, 2022. 
 
You asked the Plan to pay for remote monitoring services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote monitoring 
services provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that network providers did not render adequate 
care. The Plan denied your request. The Plan says network providers are available to render necessary 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 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 
office visits 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 waive the coinsurance for the gel-one injection provided on January 
25, 2022. 
 
You asked the Plan to waive the coinsurance for the gel-one injection. You say that you have never had to pay 
coinsurance for these services, only a $45 copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the gel-one injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total you owe is $214.94 ($1074.72 allowed amount x 20% coinsurance = $214.94). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the gel-one injection provided 
on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the complete denture - mandibular 
(D5120). We also decided the Plan does not have to pay for the unspecified removable prosthodontic 
procedure, by report (D5899) provided on October 19, 2022. 
 
You asked the Plan to provide reimbursement for dental service represented by D5120. You also asked the Plan 
to pay for the unspecified removable prosthodontic procedure, by report dental service code D5899. You say 
that you are asking for a refund from the dentist since the work was never done. The Plan denied your request. 
The Plan says the coinsurance was appropriately applied to the dental services represented by D5120. The Plan 
says that the dental service represented by code D5899 is not covered under your 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 a 50% 
coinsurance for complete dentures maxillary (upper) or mandibular (lower). 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. 
 
You have been asked to pay a 50% coinsurance for the dental services represented by code  D5120. This 
service falls within the complete dentures benefits 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 provide reimbursement 
for a complete denture - mandibular (D5120) provided on October 19, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental service represented by code 
D5899 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the unspecified removable prosthodontic procedure, by report (D5899).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
September 23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you do not agree with 
the copayment applied to this service. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 
copayment for each basic imaging service, including x-rays. 
 
You have been asked to pay a $20 copayment for a diagnostic mammogram. This item/service falls within the 
each basic imaging service, including x-rays 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 diagnostic mammogram provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral cerumen (earwax) removal provided on October 14, 
2022. 
 
You asked the Plan to pay for bilateral cerumen (earwax) removal. You say that you believed you were a 
participating provider and did not need a prior authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for bilateral cerumen 
(earwax) removal provided on October 14, 2022.