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

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 25, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this copayment should 
be waived because it was for a COVID test. 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 $15 
copayment for covered visits or consultations with a specialist. 
 
You have been asked to pay a $15 copayment for the specialist office visit. This item/service falls within the 
covered visits or consultations with a specialist 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 specialist office visit provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 29, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the records provided support 
medical necessity. 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 the domiciliary or rest 
home visit provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313) and 
cell phone mount (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and cell phone mount. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to 
control the power options through the joystick. The Plan also says that a cell phone mount (K0108) is not 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are not medically necessary 
when there is not a medical need to control the power options through the joystick. The rules also say that for 
equipment to be covered, it must primarily serve a medical purpose.    
 
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 and cell phone 
mount. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the 
provided records document that the enrollee has greater than 3/5 bilateral upper extremity strength and is 
independent with toileting, self-feeding, and meal preparation thus indicating she has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. 
 
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. A cell phone mount does not serve 
a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
the upgraded electronics (E2311, E2377, E2313) and cell phone mount (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on November 17, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you were unaware this was an out-of-network 
service. 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 chiropractic care 
provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
11, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you disagree with the 
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 a $35 
copayment for urgently needed services. 
 
You have been asked to pay a $35 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on December 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has been successfully treated with average volume assured pressure support (AVAPS) 
settings. The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability. The Plan has indicated coverage for such a device is available upon request.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230) and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on October 24, 2022. 
 
You asked the Plan to pay for a swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract 
x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray) which is an excluded place of service per the Medicare LCD coverage criteria.  
Based on this information, we decided that Medicare rules for coverage of a swallowing function x-ray  
(CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided 
that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and an upper gastrointestinal 
tract x-ray (CPT 74240) provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve two (2) additional sessions of IMRT. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not 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 the services. Our physician reviewer 
found up to 45 fractions of IMRT would be within accepted standards of medical practice and 30 is a 
reasonable approach for high-risk disease. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve two (2) additional sessions of IMRT.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve the CT scan. You say that this service is necessary to assess for renal artery 
stenosis. The Plan denied your request. The Plan says the request is not reasonable and necessary under 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found the rationale for ordering CT of the abdomen 
and pelvis is to search for other causes of hypertension. The blood and urine tests used to screen for such 
tumors has been shown to be uniformly normal. In the absence of abnormal blood or urine level, the medical 
necessity of the requested CT of the abdomen and pelvis has not been established. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an axial rotation unit, with or without adjustability 
(L5984), and vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve an axial rotation unit and shock reducing pylon. You say that the requested 
prosthetic is medically necessary for the enrollee. The Plan denied your request. The Plan says the shock 
reducing pylon and the advanced multi-axial ankle exceeds the enrollee's medical need. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components maybe covered when certain 
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 an axial rotation unit and shock reducing pylon. Our reviewer says that an axial rotation unit and shock reducing pylon are not medically 
necessary. Our physician reviewer found the provided physician documentation does not reveal a clear 
rationale for the axial rotation unit. The reviewer found that the shock reducing pylon also exceeds the 
enrollee's needs. The documentation does not indicate in the physician documentation of the need for a shock 
reducing pylon feature for the enrollee's functional level and activities. Therefore, the reviewer found that the 
requested axial rotation unit and shock reducing pylon 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 an axial rotation unit and shock reducing pylon have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an axial rotation unit, with or without adjustability 
(L5984), and vertical shock reducing pylon feature (L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on November 28, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you were unaware this was an out-of-network 
service. 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 chiropractic care 
provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices and accessories are 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
group 3 wheelchair criteria is not met as there is no high risk for skin breakdown. The enrollee has no skin 
issues despite the chronicity of illness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management visit provided on January 19, 2022. 
 
You asked the Plan to pay for a pain management visit. You say that this was medically necessary and should 
be covered. 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 a pain management visit 
provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walk-in bathtub provided on August 24, 2022. 
 
You asked the Plan to pay for the walk-in bathtub. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says a walk-in bathtub is not covered by Medicare 
or the Plan. 
 
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 pay for the walk-in bathtub provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on November 07, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. You depend on the facility to get the proper authorizations. 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 a nursing facility visit 
provided on November 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided by an 
out-of-network provider on October 25, 2022. 
 
You asked the Plan to pay for the dental service. You say that this is the first time you have had a problem with 
dental. The Plan denied your request. The Plan says the denial of payment for the intraoral radiographic images 
is correct because they are not covered by 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic images (D0210) provided by an out-of-network provider on October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on November 22, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you disagree 
with the 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 a $250 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests/Medicare-covered 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 computed tomography (CT) scan provided on November 22, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that there is an authorization on file for these 
services. The Plan denied your request. The Plan says they have agreed to pay for the therapy services; 
however, procedure code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
December 1, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you cannot afford the 
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 a $90 
copayment for each emergency care visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on December 1, 2022.