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

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you want your daily life back. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 criteria for coverage are not met. Our physician reviewer found a seat lift mechanism is covered for severe 
hip or knee arthritis or for severe neuromuscular disease. The records do not show that you have one of these 
diagnoses. The records also do not show that you are completely incapable of standing up from a regular chair. 
The seat lift mechanism is therefore not reasonable or 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 seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have bilateral feet pain, deformities, and 
Achilles tendonitis. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve meningiomatosis tumor genetic testing. 
 
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 next generation sequencing 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 has multiple meningiomas 
on recent imaging. She does not meet the criteria for a clinical diagnosis of neurofibromatosis type II. The 
documentation does not support that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer, and has decided to seek further cancer treatment. The clinical documentation does not 
support that the genetic testing in this case is medically reasonable and necessary and will impact the 
management and outcome of the enrollee in this case. 
 
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 meningiomatosis tumor genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for cataract surgeries and related supplies 
provided on April 6, 2021, and May 4, 2021.  
You asked the Plan to waive the cost-sharing for cataract surgeries and related supplies. You say that you had 
cataract surgery in 2020 and only paid $100 per eye. The Plan denied your request. The Plan says the cost-
sharing applied was 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 $400 
deductible for Medicare-covered medical supplies. Your contract with the Plan also clearly says that you must 
pay a 20% coinsurance for in-network Medicare-covered medical supplies and a $100 copayment for in-
network Medicare-covered surgery. 
 
 
Date of Service Service Provided Allowed Amount Cost Sharing Your Responsibility 
4/6/2021 Medical Supplies $310.80 $310.80 Deductible $310.80 
4/6/2021 Medical Supplies $198.00 
-$89.20 
$108.80 
 
$89.20 Deductible 
20% Coinsurance 
 
$89.20 
$21.76 
4/6/2021 Outpatient Surgery $514.00 $100 Copayment $100 
5/4/2021 Medical Supplies $310.80 20% Coinsurance $62.16 
5/4/2021 Medical Supplies $198.00 20% Coinsurance $39.60 
5/4/2021 Outpatient Surgery $514.00 $100 Copayment $100 
    Total: $723.52 
 
 
You have been asked to pay $723.52 for cataract surgeries and related supplies. Surgical supplies fall within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. Cataract surgery falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgery centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for cataract 
surgeries and related supplies provided on April 6, 2021, and May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contrast injection (Q9965) provided May 13, 2021. 
 
You asked the Plan to pay for the contrast injection. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code Q9965 is Low-osmolar contrast material, 100-199 mg/ml 
iodine concentration, per ml for service provided. 
 
We find that CPT code Q9965 is not supported in the medical record. Specifically, the procedure report 
provided does not document this service. Based on this information, we decided that Medicare rules for 
coverage of the contrast injection have not been met. Therefore, we decided that the Plan does not have to pay 
for a contrast injection (Q9965) provided May 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on December 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition. 
 
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 radiology services provided to the enrollee on December 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the services of a private-duty nurse or other private-
duty attendant are not covered. 
 
We looked at the file and Medicare rules. The services at issue are private duty nursing. These services are not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve private duty nursing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) or pay more for the progressive lens 
(V2781) provided on November 17, 2021. 
 
You asked the Plan to pay for the frames and to pay more for the progressive lens. You say that you have not 
received any reimbursement. The Plan denied your request. The Plan says your $150 eyewear benefit 
allowance was exhausted with this purchase. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $150 allowance every 24 months that you can use to pay for eyewear, and you 
are responsible for any difference if your purchase costs more than $150. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $150 for the progressive lens 
(V2781) provided on November 17, 2021. Based on this information, we decided that the Plan's rules for 
coverage of the frames and progressive lens have not been met. Therefore, we decided that the Plan does not 
have to pay for the frames (V2020) or pay more for the progressive lens (V2781) provided on November 17, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on September 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services were 
billed twice. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 pay for the emergency services provided on September 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on January 20, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you would like to request reconsideration 
and that no authorization is needed. The Plan denied your request. The Plan says the provider is out-of-
network, there isn't a referring provider and it was determined these services were not urgent or emergent. 
 
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 had network providers 
available who could have provided 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 Home Health Services provided on January 20, 
2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel surgery consultation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the carpal tunnel surgery consultation. You say that want to see the out-of-
network physician because you have seen this same group of providers before and you are comfortable with 
them. The Plan denied your request. The Plan says the provider is out-of-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 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 carpal tunnel surgery consultation in this appeal. We found no exception that 
would require the Plan to pre-approve the carpal tunnel surgery consultation. Therefore, we decided that the 
Plan does not have to pre-approve carpal tunnel surgery consultation to be provided by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for a prostate biopsy provided on 
January 20, 2022. 
 
You asked the Plan to increase the reimbursement for a prostate biopsy. You say that you asked for 
reimbursement for the $1,000 you paid for a prostate biopsy. You also say that you were surprised when the 
Plan only reimbursed you $124.00. The Plan denied your request. The Plan says you were reimbursed 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 if you receive the 
covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance 
percentage multiplied by the Medicare payment rate for participating providers. 
 
The record shows you were reimbursed the correct amount based on the Medicare fee schedule for a prostate 
biopsy. You have been reimbursed a total of $124.40 for a prostate biopsy. A prostate biopsy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to increase the reimbursement for a prostate biopsy 
provided on January 20, 2022.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for this walker. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence panel of 51 or greater genes 
provided to the enrollee on December 15, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the denial of a targeted genomic sequence panel of 51 or greater genes was appropriate given the 
clinical scenario. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the request for a panel of 51 or greater genes is not reasonable or 
medically necessary. The review has determined that the services at issue in this case are not medically reasonable or necessary, given the clinical scenario. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a targeted genomic sequence panel of 51 or greater genes provided to the enrollee on December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you provided medical records and would like the 
claim to be processed using out of network benefits. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
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 had network providers 
available who could have provided 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 an office visit provided on January 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on September 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and the chiropractic manipulative 
treatment (98940) rendered by the out-of-network (OON) provider on September 2, 2021. 
 
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 had network providers available 
who could have provided 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 office visit (99202) and the chiropractic manipulative treatment (98940) 
rendered by the out-of-network (OON) provider on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 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. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services coded 80307 provided on November 
29, 2021. 
 
You asked the Plan to pay for drug testing services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has processed correctly 
based on Medicare coding rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and Medicare rules. In this case, the Plan has made payment for one unit of CPT code 
80307. According to Medicare rules, only one code may be reported from the range 80305-80307 per date of 
service. Based on this information, we decided that Medicare rules for coverage of an additional billed unit of 
drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing services coded 80307 provided on November 29, 2021.