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

 
We decided that the Plan does not have to pre-approve an electrical connection (E2311), foot plate (K0108), 
privacy flap (K0108), and elevating leg rests (K1012). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories 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 wheelchair accessories. Our 
reviewer says that the requested features are not medically necessary. Our physician reviewer found 
documentation does not reveal that the patient has leg edema, contractures in the lower extremities, or an 
inability to flex her knee. The elevated leg rests exceed the enrollee's needs. Only one power system has been 
approved, so the requested electrical connection for 2 or more power features is not medically necessary. The foot plate and privacy flap are not primarily medical and are non-covered. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electrical connection (E2311), foot plate (K0108), privacy flap (K0108), 
and elevating leg rests (K1012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on February 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 7, 
2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that since they found polyps that's a 
reason why the procedure should be covered. The Plan denied your request. The Plan says the copayment 
applied is 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 $290 
copayment for each Medicare covered outpatient hospital facility visit.  
 
You have been asked to pay $290 copayment for colonoscopy. Colonoscopys fall 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 waive the copayment for a colonoscopy provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 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 an office visit provided on January 14, 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 psychotherapy sessions provided on March 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy sessions. You say that you were told that the provider was an 
in-network provider. The Plan denied your request. The Plan says the rendering and referring providers are 
both OON providers and there was no approved authorization. Also, it was confirmed there are no record of the 
enrollee being told that the provider is an in-network provider. 
 
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 psychotherapy sessions provided on March 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on February 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was coded incorrectly and that's 
why you have this copayment. The Plan denied your request. The Plan says the copayment applied is 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 $20 
copayment for primary care physician visit.  
 
 
 
 
 
 
 
 You have been asked to pay $20 copayment for office visit. Office visits fall 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 office visit provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent nursing facility care provided on February 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent nursing facility care. 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 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 Subsequent nursing facility care provided on 
February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass lens enhancements provided on March 17, 2022. 
 
You asked the Plan to pay for eyeglass lens enhancements. The Plan denied your request. The Plan says lens 
enhancements are not a covered vision benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 
 We looked at the file and the Plan's rules. The file shows that lens enhancements are not a covered routine 
vision benefit. Therefore, we decided that the Plan does not have to pay for eyeglass lens enhancements 
provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor (code 33285) and 
event recorder, cardiac (implantable) (code C1764). 
 
You asked the Plan to pre-approve subcutaneous cardiac rhythm monitor and event recorder, cardiac 
(implantable). You say that subcutaneous cardiac rhythm monitor and event recorder, cardiac (implantable) is 
medically necessary. The Plan denied your request. The Plan says subcutaneous cardiac rhythm monitor and 
event recorder, cardiac (implantable) does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 subcutaneous cardiac rhythm monitor 
and event recorder, cardiac (implantable). Our reviewer says that subcutaneous cardiac rhythm monitor and 
event recorder, cardiac (implantable) is not medically necessary. Our physician reviewer found that there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR.  In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subcutaneous cardiac rhythm monitor and event recorder, cardiac (implantable) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve subcutaneous cardiac 
rhythm monitor (code 33285) and event recorder, cardiac (implantable) (code C1764).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 home test (U0002) provided on April 7, 2022, 
while traveling outside of the United States. 
 
You asked the Plan to pay for a COVID-19 test. You say that you had to take a COVID-19 test to return to the 
United States per government entry requirements. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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, a COVID-19 test, was requested solely for screening for the purposes of travel. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for a COVID-19 home test (U0002) provided on April 7, 2022, while traveling outside of the 
United States.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation of wheezing and for the diffusing capacity 
provided on March 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation of wheezing and for the diffusing capacity. You say that the 
services were medically necessary and reasonable for the treatment of the enrollee's condition. The Plan denied 
your request. The Plan says their records indicate that you are a non-contracted provider with the Plan. You 
also say that there is no record of a request for prior authorization prior to offering these services, which were 
not urgent or emergent in nature. The Plan also says that the medical records indicate that the enrollee was 
referred to your facility by a provider who is not contracted with the Plan. 
 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 evaluation of wheezing and for the diffusing 
capacity provided on March 19, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 21, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you never received any medications 
that you took by mouth. The Plan denied your request. The Plan says self-administered drugs are not covered 
under Medicare health. 
 
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 pay for the self-administered drugs 
provided on February 21, 2022.  
 
 
 Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast prosthesis, every six (6) months to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the breast prosthesis. You say that you need the breast prostheses because 
you are traumatized without it. The Plan denied your request. The Plan says there are in-network providers that 
you can get the prostheses from. 
 
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. Furthermore, the rules say that the useful lifetime expectancy for 
silicone breast prostheses is 2 years. Replacement sooner than the useful lifetime because of ordinary wear and 
tear will be denied as noncovered. Therefore, we decided that the Plan does not have to pre-approve the breast 
prosthesis, every six (6) months to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Glucose, blood by glucose monitoring device provided on 
June 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Glucose, blood by glucose monitoring device. 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 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 Glucose, blood by glucose monitoring device 
provided on June 8, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you went to get a COVID-19 test since 
you were around infected people and thought it was covered. The Plan denied your request. The Plan says the 
copayment applied is 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 $90 
copayment for each ER visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall 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 ER visit provided on March 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray on April 7, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you would like to appeal the cost share. 
The Plan denied your request. The Plan says the copayment applied is 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 $85 
copayment for an x-ray. The allowed amount on this claim is $72.39, which is less than the $85 copayment, 
therefore the entire allowed amount went towards the member's copay for outpatient basic radiology services. 
 
You have been asked to pay a $85 copayment for an x-ray. An x-ray falls within the Outpatient hospital 
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 x-ray on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure (81479) provided on April 
12, 2021. 
 
You asked the Plan to pay for molecular pathology services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for molecular pathology services was not filed until April 21, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a molecular pathology procedure (81479) provided on April 12, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on September 3, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that this is too much to pay. The Plan denied 
your request. The Plan says the copayment applied is 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 $350 
copayment for diagnostic radiology other than CT scans.  
 
You have been asked to pay $350 copayment for MRI. MRIs fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
MRI provided on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 14, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was medical vision check (age-related nuclear cataract- right eye, presence of 
intraocular lens, presbyopia). 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on April 14, 2022.