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

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on November 
30, 2021. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you were told that you would 
not be charged a copayment for the phone call. You say that had you known there was a copayment you would 
not have accepted the call. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 for each Medicare-covered specialist office visit. Telehealth services, including consultation, 
diagnosis and treatment by a physician or practitioner, including primary care physician (PCP) and specialist 
visits.  
 You have been asked to pay $37.39 which is less than the standard $50 copayment. The telehealth 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 telehealth visit provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve artificial leg to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve artificial leg. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
artificial leg to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic monitoring services provided to the enrollee on 
July 21, 2021. 
 
You asked the Plan to pay for the serivces. You say that this should be paid for. The Plan denied your request. 
The Plan says the rendering provider is not an eligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. Coventry did not pre-approve the serivces. We found no 
exception that would require Coventry to pay for these items/services. Based on this information, we decided 
that Medicare rules for coverage of the serivces have not been met. Therefore, we decided that the Plan does 
not have to pay for diagnostic monitoring services provided to the enrollee on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the durable medical equipment (DME) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that you are appealing the denied coverage with the 
OON provider. The Plan denied your request. The Plan says the requested provider is an OON provider and a 
list of multiple in-network providers who provide the same quality of service was sent to the enrollee. 
 
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 
the durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana 300mg tablets. 
 
You asked the Plan to pre-approve Invokana. You say that Invokana is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana 300mg tablets.  
 
Benefits for Invokana may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit and injection provided on January 24, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and injection. You say that these services were preauthorized by 
the plan. The Plan denied your request. The Plan says that the services were provided out-of-network and were 
not approved in advance. 
 
On June 13, 2021, the Plan pre-approved the items/services at issue from this provider with an expiration date 
of June 11, 2022. Therefore, we decided that the Plan has to pay for the office visit and injection provided on 
January 24, 2022 by an out-of-network (OON) provider.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT Percutenous Peripheral Nerve Stimulator 
(PNS) system. 
 
You asked the Plan to pre-approve a SPRINT Percutenous PNS system. 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 PNS trials 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 SPRINT Percutenous PNS system. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record 
provided indicates that a sciatic nerve block was 80% effective in providing pain relief. The record as provided 
is insufficient to demonstrate the  coverage criteria are satisfied.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
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 SPRINT Percutenous PNS system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a SPRINT Percutenous Peripheral Nerve Stimulator (PNS) system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on December 7, 2021. 
 
You asked the Plan to pay for the serices. You say that the provider was eligible to provide these services. The 
Plan denied your request. The Plan says that the provider is not certified or eligible to paid for this procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. It appears Certified Registered Nurse 
Anesthetists (CRNAs) are eligible to provide anesthesia services. The plan has not stated why the CRNA at 
issue in this case would not have been eligible to provide this service. Therefore, we decided that the Plan has 
to pay for anesthesia services provided to the enrollee on December 7, 2021.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychosocial rehabilitation services provided from 
February 21, 2022, to February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychosocial rehabilitation services. You say that you would like the claims 
reprocessed because the service provided to the enrollee was medically necessary and the service provided does 
not need prior authorization. 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. Also, the service 
rendered was 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 the psychosocial rehabilitation services provided 
from February 21, 2022, to February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy sessions to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy sessions. You say that the requested OON provider is 
only a couple of miles away and you would like to see them. The Plan denied your request. The Plan says there 
is an approved authorization to see an in-network provider and a list of multiple in-network providers was 
given to the enrollee that are within the distance standards. Also, if the enrollee needs transportation, it is 
available through the Plan's supplemental benefits. 
 
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 
the physical therapy sessions to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device to 
be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested item. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device to be rendered by the out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the cardiovascular stress test (93015) and 
the Rubidium rb-82, diagnostic, per study dose (A9555) provided on November 6, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
item/service provided. 
 
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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Additionally, you must pay a 20% 
coinsurance for each Medicare Part B drug.  
 
 
  
You have been asked to pay $238.30 ($208.30 + $30). This amount includes a $30 copayment for the 
Medicare-covered non-radiological diagnostic service provided. Additionally, this amount includes the Plan 
allowed amount of $1,041.50 x 20% coinsurance=$208.30 for the Medicare-covered Part B drug provided. 
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 share for the cardiovascular stress test (93015) and the Rubidium rb-
82, diagnostic, per study dose (A9555) provided on November 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Physical Therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Physical Therapy. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
Physical Therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 31, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on August 31, 2021 
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 office visit provided on June 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services should be processed as in-network. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not 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 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 the office visit provided on June 18, 2021 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Emerg Auto-Emersion Therapy system. 
 
You asked the Plan to pre-approve an Emerg Auto-Emersion Therapy system. 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 a Group 1 mattress overlay or mattress (E0181, 
E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199 and A4640) is covered if 
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 an Emerg Auto-Emersion Therapy 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
Emerg Auto-Emersion Therapy system exceeds your medical needs and is not medically necessary per Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The requested item has touchscreen technology 
and automatic sensors for pressure adjustment which are not medically necessary for wound healing. The 
documentation does not reveal extenuating factors that would require a mattress with these deluxe features over 
a standard pressure reducing support surface. 
 
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 Emerg Auto-Emersion Therapy system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Emerg Auto-Emersion Therapy system.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of spine and pelvis. 
 
You asked the Plan to pre-approve an MRI of spine and pelvis. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of spine and pelvis. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the requested MRI 
exams of the lumbar spine and pelvis are indicated and will allow assessment of known sites of metastatic 
disease as well as the symptomatic right hip which also may be involved as well. 
 
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 MRI of spine and pelvis have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of spine and pelvis.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81292) provided August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81292) provided August 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation. You say that the services are 
necessary. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation.