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

 
We decided that the Plan does not have to pay for the x-ray exam of the knee (73562), the hospital outpatient 
clinic visit (G0463), the needle electromyography (95886), and the nerve conduction studies (95912) rendered 
by the out-of-network (OON) provider on November 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 x-ray exam of the knee (73562), the hospital outpatient clinic visit (G0463), 
the needle electromyography (95886), and the nerve conduction studies (95912) rendered by the out-of-
network (OON) provider on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography (CT) 
scan (70496) provided on September 30, 2021. 
 
You asked the Plan to waive the copayment for the computed tomographic angiography (CT) scan. You say 
that the services should be covered in full. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $150 copayment for the computed tomographic angiography (CT) scan. CT 
scans 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 a computed tomographic angiography (CT) scan (70496) 
provided on September 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you called the Plan beforehand and were advised the provider was in-network. The Plan denied 
your request. The Plan says the cost-sharing applied correctly based on the services provided, there is no record 
of you calling the Plan beforehand to verify the providers network status and that the copayment would be the 
same regardless of their network status. 
 
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 $20 
copayment for Outpatient rehabilitation services.  
 
 
 
 You have been asked to pay a $20 copayment for physical therapy services. Physical therapy services falls 
within the Outpatient rehabilitation 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 physical therapy services provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON office visits. You say that the enrollee is requesting to see the 
OON provider because he speaks Spanish, and she will be able to communicate with him directly. The Plan 
denied your request. The Plan says the services can be provided by an in-network Spanish speaking podiatrist. 
 
  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. The Plan verified that they have network 
podiatrists who are Spanish speaking. We found no exception that would require the Plan to pre-approve these 
OON services. Therefore, we decided that the Plan does not have to pre-approve office visit services 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 full-length hospital bed rails for the enrollee. 
 
You asked the Plan to pre-approve the rails. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover full length bed side rails when used as a restraint to prevent 
falls or wandering. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
These bed rails are not being requested for a medical purpose. Therefore, we decided that the Plan does not 
have to pre-approve full-length hospital bed rails for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hot tub (E1399) purchased April 23, 2021. 
 
You asked the Plan to pay for a hot tub. You say that the water therapy provided by this hot tub relaxes the 
muscles and reduces the cramps tremendously. This gives you relief where pain medication does not. The Plan 
denied your request. The Plan says this item is not a covered under Medicare or the Plan. 
 
  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a hot tub (E1399) purchased April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), removal of benign 
odontogenic cyst or tumor (D7450), sedation services (D9222, D9223 x 3), and therapeutic parenteral drugs 
(D9612) provided on October 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you required intravenous (IV) antibiotics to 
prevent sepsis due to an infected tooth and cyst. You also say that you would not get this service done 
anywhere but the emergency room. The Plan denied your request. The Plan says the claim was processed 
correctly according to the Evidence of Coverage. 
 
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 limited oral evaluation, removal of 
benign odontogenic cyst or tumor, and therapeutic parenteral drug are not among those covered under this 
benefit. The Evidence of Coverage states that anesthesia is covered with other covered procedures. Since the 
associated services are not covered, the anesthesia services are not covered either. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation (D0140), removal of benign odontogenic cyst or 
tumor (D7450), sedation services (D9222, D9223 x 3), and therapeutic parenteral drugs (D9612) provided on 
October 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on September 22, 
2021. 
 You asked the Plan to pay for therapeutic activities. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
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 find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Certified 
Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on 
September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for wrist surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medically reasonable explanation for why this wrist surgery is to be done 
with an out-of-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 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 
an out-of-network referral for wrist surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the requested MyoPro powered 
arm brace is medically necessary. The Plan denied your request. The Plan says the requested MyoPro powered 
arm brace is not medically necessary. 
 
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 pre-approve a MyoPro powered arm brace. Our 
reviewer says that the requested MyoPro powered arm brace is not medically necessary. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term 
use. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities.  
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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise pulley set. 
 
You asked the Plan to pre-approve the equipment. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
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 an exercise pulley set.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on 
November 18, 2021, billed with code 76705. 
 
You asked the Plan to pay for the ultrasound interpretation. You say that multiple exams were provided on this 
date. The Plan denied your request. The Plan says multiple exams were provided, but the claim is not billed 
with the required modifier to allow payment. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on 
November 18, 2021, billed with code 76705.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that PBRT is a Food and Drug Administration (FDA) 
approved treatment modality that allows precision of the proton beam and improved control of the radiation 
dose prescribed to the gross tumor and areas at risk for microscopic disease. You say that PBRT is very clearly 
the preferred option to reduce the risk of treatment related secondary malignancy. The Plan denied your 
request. The Plan says PBRT is not the standard of care for prostate cancer. 
 
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 pre-approve PBRT. Our reviewer says that PBRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found proton therapy 
for prostate cancer is not experimental, and in fact is an accepted treatment approach.  While our physician 
reviewer does not think that proton therapy is an experimental therapy, any potential benefit or detriment of 
proton therapy over standard intensity-modulated radiation therapy (IMRT) is an investigational question 
(being pursued in randomized studies.) Other treatment approaches such as IMRT and image-guided radiation therapy (IGRT) are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over 
other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains 
controversial. To date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient service to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve outpatient service. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
provider is out-of-network with the Plan and the enrollee can be treated within the Plan 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 
outpatient service to be provided 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 comprehensive audiometry threshold evaluation and 
speech recognition test (92557) rendered by the out-of-network (OON) provider on November 22, 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 comprehensive audiometry threshold evaluation and speech recognition test 
(92557) rendered by the out-of-network (OON) provider on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network office visit (99214) 
provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered in 
full as the provider is a network provider. The Plan denied your request. The Plan says the cost-sharing applied 
correctly and the rendering provider is out-of-network. 
 
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 $65 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $65 copayment for an office visit. The record indicates that the provider is out-
of-network, therefore, no adjustments will be made. 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 out-of-network office visit (99214) provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the 
out-of-network (OON) provider on August 25, 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) 
provider on August 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the requested IMRT for the treatment of metastatic 
prostate cancer is medically necessary. The Plan denied your request. The Plan says the requested IMRT does 
not meet criteria. 
 
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 pre-approve IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the assessment and plan describe the benefit of pelvic radiotherapy for patients with 
limited metastatic disease, nothing in the case records describe how this patients disease qualifies as limited. 
There is no specific rationale for the need of IMRT using quantifiable dosimetric measures, which is what the 
ASTRO model policy requires for clinical scenarios for which IMRT is not standard. As IMRT for palliation 
would not be furnished in accordance with accepted standards of medical practice, without providing a 
dosimetric rationale showing a plausible, clinically meaningful benefit (which would be unexpected when 
using palliative dosing), my decision is unfavorable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT).