Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on September 1, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you are disputing the share cost. 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 $290 
copayment for ambulance services.  
 
You have been asked to pay $290 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on 
September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810) 
provided from May 13, 2022, through August 24, 2022. 
 
You asked the Plan to issue reimbursement 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 
provided do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of chronic low back pain. Therefore, we decided that the Plan does not have to issue 
reimbursement for the acupuncture treatments (97810) provided from May 13, 2022, through August 24, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance spectroscopy (76390). 
 
You asked the Plan to pre-approve magnetic resonance spectroscopy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve magnetic resonance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has had magnetic resonance imaging (MRI) scans in the past which 
showed progressive ventricular dilatation and increase in periventricular white matter changes suspicious for 
normal pressure hydrocephalus (NPH). A follow-up MRI of the brain was planned in the notes of October 3. 
2022 but not done yet. The plan for a follow-up MRI of the brain in this enrollee with progressive ataxia and 
ventriculomegaly is appropriate. At that sitting the addition of MR proton spectroscopy would be of benefit as 
this study has been used to assess the potential benefit of shunting in patients with NPH. While no mass is 
apparent on prior studies the probable diagnosis of NPH is reasonable and the MR proton spectroscopy would 
be helpful to determine if interventional shunt therapy is likely to be of benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance spectroscopy have been met. Therefore, we decided that the 
Plan has to pre-approve magnetic resonance spectroscopy (76390).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystoscopy procedure provided on August 05, 2022. 
 
You asked the Plan to pay for a cystoscopy procedure. You say that you would like the medical records to be 
reviewed and denial reconsidered. 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 cystoscopy procedure 
provided on August 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the bathtub seat (E1399) purchased on 
August 12, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that bathtub seats are not covered because they are 
considered a comfort or convenience item; and hygienic equipment that is not primarily medical in nature.  
 
While a bathtub seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to issue reimbursement for the bathtub seat (E1399) 
purchased on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement provided on June 17, 2022. 
 
You asked the Plan to waive the copayment for debridement. You say that you appealed a copayment 
previously and it was waived, so you would like this copayment waived. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $171.25, which is less than the standard $295 copayment for debridement. This 
debridement falls within the Outpatient surgery and other medical 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 waive the copayment 
for debridement provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 08, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were 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 the laboratory services 
provided on August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on May 16, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain the proper 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 a nursing facility visit 
provided on May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) colonography. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
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 services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that there were no 
records provided to support that the enrollee has failed a conventional colonoscopy. The medically appropriate 
test for the enrollee's circumstance of microcytic anemia is traditional colonoscopy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) colonography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over the bed tray table (E0274). 
 
You asked the Plan to pre-approve the over the bed tray table. You say that you want this item. The Plan denied 
your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 pre-approve the over the bed tray table (E0274).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bladder instillation services provided on June 15, 2022 to 
June 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for bladder instillation services. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services provided. 
 
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 bladder instillation services provided on June 15, 
2022 to June 22, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do 
not need the services of a skilled physical therapist. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that you do not have documented, ongoing skilled physical therapy needs. You are functioning 
at a level commiserate with a lower level of care. As such, the requested, ongoing, home health physical 
therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on August 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that the provider had no prior 
knowledge of the individuals they will be required to see. The Plan denied your request. The Plan says 
authorization was not obtained prior to services being rendered. 
 
 
 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 principal care management services provided on 
August 11, 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 office visit and wound care services provided on July 06, 
2022. 
 
You asked the Plan to pay for the office visit and wound care services. You say that the services do not require 
a PCP referral. 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 office visit and 
wound care services provided on July 06, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sleeve gastrectomy. 
 
You asked the Plan to pre-approve the repeat procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says repeat bariatric surgery is generally not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat bariatric surgery is generally not 
reasonable and 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 repeat procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that repeat sleeve gastrectomy is not a standard re-operative procedure and has been 
documented in published literature to have a high risk of potential morbidity secondary to complications such 
as leak. It has not been documented to have sustainable durable efficacy in published literature. This patient has 
normal anatomy and a BMI that is less than 35 kg/m2. 
 
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 repeat procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sleeve gastrectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should be 
covered. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim crown (D2799), a surgical placement of implant 
body (D6010), a prefabricated abutment (D6056), an extraction of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), and an abutment supported porcelain/ceramic crown (D6058) provided 
from August 30, 2021, to October 21, 2021. 
 
  You asked the Plan to pay for an interim crown (D2799), a surgical placement of implant body (D6010), a 
prefabricated abutment (D6056), an extraction of an erupted tooth requiring removal of bone and/or sectioning 
of tooth (D7210), and an abutment supported porcelain/ceramic crown (D6058). You say that this was a 
necessary surgery as the main problem was your jawbone collapsing as shown in the pictures you submitted. 
The Plan denied your request. The Plan says though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested services, an interim crown (D2799), a surgical placement of implant body (D6010), a 
prefabricated abutment (D6056), an extraction of an erupted tooth requiring removal of bone and/or sectioning 
of tooth (D7210), and an abutment supported porcelain/ceramic crown (D6058) are excluded from coverage 
and not covered benefits. 
 
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 pay for an interim 
crown (D2799), a surgical placement of implant body (D6010), a prefabricated abutment (D6056), an 
extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and an abutment 
supported porcelain/ceramic crown (D6058) provided from August 30, 2021, to October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), teeth 
cleaning (D1110), and a complete series of radiographic images (D0210) provided on July 18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you want the Plan to make an exception to 
the out-of-network liability rule. The Plan denied your request. The Plan says the enrollee is responsible for any 
charged amount above the Plans cost-sharing amount when the services are received from an out-of-network 
provider. 
 
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. 
 
   
The enrollee has been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation the enrollee agreed to pay when the enrollee enrolled in 
the Plan. Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation 
(D0150), teeth cleaning (D1110), and a complete series of radiographic images (D0210) provided on July 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (86480, 86735, 86762, 86765, 86787) 
provided on August 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says screening tests are not covered by Medicare. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
lab services (86480, 86735, 86762, 86765, 86787) provided on August 9, 2022.