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

 
We decided that the Plan does not have to pre-approve the injection, Ferumoxytol, for treatment of iron 
deficiency anemia, 1 mg (Q0138). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has anemia and requires an iron 
infusion. The Plan denied your request. The Plan says the requested necessary information was not received to 
make a decision about paying for the Part B drug, Ferumoxytol 510 MG/17 ML VIAL. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection have been met. medical 
records were needed to be able to determine if the requested service is medically necessary. The records show 
that the Plan made multiple attempts to obtain the needed records from the provider without success. Therefore, we decided that the Plan does not have to pre-approve the injection, Ferumoxytol, for treatment of iron 
deficiency anemia, 1 mg (Q0138).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an implantable cardiac monitor (ICM) in this enrollees 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultra-lightweight wheelchair and accessories coded as 
K0005, E2611, E0990, K0040, E0951, E0961, E0973, E0971 and E2601 
 
You asked the Plan to pre-approve the wheelchair. You say that the medical records provided support the 
necessity of the requested service in dispute. The Plan denied your request. The Plan says the requested 
wheelchair is not medically necessary. Backup chairs are denied as not reasonable and necessary 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Group 2 power wheelchair (K0823) that was delivered March 19, 2019. The 
Group 2 power wheelchair (K0823) serves the same purpose as the wheelchair. Payments are made for only 
one wheelchair at a time. Therefore, we decided that the Plan does not have to pre-approve ultra-lightweight 
wheelchair and accessories coded as K0005, E2611, E0990, K0040, E0951, E0961, E0973, E0971 and E2601
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) Panel 
(87798, 87481) provided on May 27, 2022. 
 
You asked the Plan to pay for the infectious disease (PCR) panel. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says criteria are not met for PCR testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the infectious disease (PCR) panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollees right hallux toenail needed to undergo PCR testing when 
other less expensive and efficacious lab tests are available. Therefore, it is my opinion that the requested PCR 
testing of this enrollees right hallux toenail was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the infectious disease (PCR) panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) Panel (87798, 
87481) provided on May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that per the treating physician, the 
enrollee meets the medically necessity outlined in the criteria. The Plan denied your request. The Plan says this 
procedure is considered experimental and unproven as there is insufficient evidence in safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage for the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the aflibercept injection provided by an in-
network provider on August 10, 2022, and September 14, 2022. 
 
You asked the Plan to waive the cost sharing for the injections. You say that you do not agree with the cost 
sharing applied to these services. 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 a 20% 
coinsurance for in-network intravenous, subcutaneous, and biological Part B drugs. 
 
 
 
 
 You have been asked to pay a cost share of $730.32 for the injections ($1825.78 allowed amount x .20 = 
$365.16 rounded up) ($365.16 x 2 injections = $730.32). These items/services fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the aflibercept 
injection provided by an in-network provider on August 10, 2022, and September 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on January 04, 2022, to July 02, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing the claim payment denial. 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 home health care 
provided on January 04, 2022, to July 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
(87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, U0003) provided on January 18, 
2022. 
 
You asked the Plan to pay for the PCR respiratory panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the PCR respiratory panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, U0003) 
provided on January 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 25, 
2022, to August 23, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee does not meet 
the clinical requirements to be approved.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 25, 2022, to August 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on September 22, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing this copayment. 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 a $115 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $115 copayment for ultrasound. This item/service falls within the other 
outpatient diagnostic tests 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. However, since the allowed amount is less than the standard copayment, you only owe 
$70.69. Therefore, we decided that the Plan does not have to waive the copayment for ultrasound provided on 
September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on October 
10, 2022, to October 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you should not have to pay 
for the extra stays because you had issues and needed a second hip replacement. 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 a $390 
copayment for inpatient hospital care. 
 
You have been asked to pay a $390 copayment for inpatient hospital stay. This item/service falls within the 
inpatient hospital 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. The total you owe is $1,170 ($390 copayment  x 3 visits = $1,170) Therefore, we decided 
that the Plan does not have to waive the copayment for inpatient hospital stay provided on October 10, 2022, to 
October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for general anesthesia (D9222/D9223). 
 
You asked the Plan to pay for general anesthesia. You say that the enrollee needs this sedation. The Plan denied 
your request. The Plan says that these services have been correctly denied. 
 
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 Plan covers general 
anesthesia when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for general anesthesia. Our physician reviewer 
found the documentation provided meets the criteria for coverage for the additional 15 minutes of general 
anesthesia/sedation per the request of the provider due to the enrollee's history of past dental procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of general anesthesia have been met. Therefore, we decided that the Plan has to 
pay for general anesthesia (D9222/D9223).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. 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 a $240 
copayment for ambulance services. 
 
You have been asked to pay a $240 copayment for ambulance services. 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 services 
provided on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided at an outpatient hospital 
on March 31, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you were only sent to the hospital 
because your provider's office does not have an x-ray machine. 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 a $100 
copayment for x-ray services provided at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic testing and 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 provided at an outpatient hospital on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 25, 2022, and 
November 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you did not know the providers were out-of-
network. The Plan denied your request. The Plan says the service can be provided by 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 laboratory services provided on October 25, 2022, 
and November 3, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and the cost share for an in-network diagnostic 
colonoscopy provided on November 3, 2022. 
 
You asked the Plan to waive the deductible and the cost share for a diagnostic colonoscopy. You say that you 
were told that you qualified for a free colon cancer screening. 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 a $225 
deductible and a 20% coinsurance for in-network Medicare-covered outpatient surgery.  
 
You have been asked to pay a total of $484.24 for a colonoscopy. The total allowed amount for this service 
$1,271.18. After the $225 deductible was applied, $1,046.18 remained, and you are responsible for a $209.24 
coinsurance ($1,046.18 x 20% = $209.24). This item/service falls within the in-network Medicare- 
covered visit to an outpatient hospital facility, certified ambulatory surgical center, or clinic 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 deductible and the cost share for an in-network diagnostic colonoscopy 
provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 26, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the claim payment denial. 
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 wound care supplies 
provided on October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
(87798) provided on November 21, 2022. 
 
You asked the Plan to pay for the PCR respiratory panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the PCR respiratory panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the polymerase chain reaction 
(PCR) respiratory panel (87798) provided on November 21, 2022.