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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on November 08, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
expecting to be billed an additional copayment for the CT scan. 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 $175 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $175 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 tomography (CT) scan provided on November 08, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit provided 
on January 04, 2023. 
 
You asked the Plan to reduce the copayment for each physical therapy (PT) visit. You say that your copayment 
applied for the PT services is incorrect and should be less. 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 $40 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 reduce the copayment 
for each physical therapy (PT) visit provided on January 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardio hereditary genetic testing provided 
October 30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria. 
 
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 laboratory service. Our physician 
reviewer found the test is described as a genetic-based cardiovascular risk factor screening test in which 
multiple genes are assessed. It identifies the presence of pathogenic, or likely pathogenic, variants in genes 
known to be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to support 
its role in this patient's clinical management. In summary, the requested testing is not considered reasonable or 
medically 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the comprehensive cardio hereditary genetic testing provided October 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on November 22, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you would 
like the copayment to be waived due to the large amount. 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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
rendered at an outpatient hospital provided on December 13, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI) rendered at an outpatient 
hospital. You say that you feel that you were not properly informed of the cost share for the MRI. 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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 copayment for a magnetic resonance image (MRI) rendered at an 
outpatient hospital. This item/service falls within the outpatient diagnostic test 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 magnetic resonance image (MRI) rendered at an outpatient hospital 
provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy evaluation provided on August 15, 
2022. 
 
You asked the Plan to pay for occupational therapy evaluation. You say that the records attached support the 
services provided. 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 occupational therapy 
evaluation provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 03, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on February 03, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head or brain without contrast. 
 
You asked the Plan to pre-approve CT scan of the head or brain without contrast. You say that for many years 
the enrollee has suffered from severe headaches. The Plan denied your request. The Plan says a CT scan of the 
head or brain without contrast. 
 
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 CT scan of the head or brain without 
contrast. Our reviewer says that the requested CT scan of the head or brain without contrast is not medically 
necessary. Our physician reviewer found that the enrollee has not had a head injury and their headaches are not 
suddenly onset. Their headaches are a chronic problem in which formal medical therapy has not been trialed or 
attempted. Therefore, the enrollee does not meet the requirements of the requested CT scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the head or brain without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the head or brain without contrast.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 17, 2022. 
 You asked the Plan to pay for lab services. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 15, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for lab services provided 
on October 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. You say that the patient needs this medication as it is the only statin 
they can tolerate. The Plan denied your request. The Plan says this drug is not covered under the patient's 
medical benefits. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.  
 
Benefits for Livalo 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
performed by a provider other than your primary care physician provided on November 01, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI) performed by a provider 
other than your primary care physician. You say that the copayment amount charged for the MRI is not correct. 
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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 copayment for a magnetic resonance image (MRI) performed by a provider 
other than your primary care physician. This item/service falls within the outpatient diagnostic test 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 magnetic resonance image (MRI) performed 
by a provider other than your primary care physician provided on November 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 13, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. 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 chiropractic services 
provided on July 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided on December 1, 2022, 
to December 7, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you should not have to pay the 
copayment for the SNF visit because you tested positive for Covid-19 and was told you needed to stay longer. 
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 $0 
copayment for days 1 to 20 and a $188 copayment for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay a $1,316 copayment for SNF care ($188 per day x 7 days = $1,316). This 
item/service falls within the SNF 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 
SNF care provided on December 1, 2022, to December 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on December 
08, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that it is the responsibility of the 
facility to obtain 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 subsequent nursing 
facility care visits provided on December 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 07, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you are high 
risk and should a MRI should be covered once a year, along with a mammogram. 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 $300 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $300 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on February 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that your current hospital bed is 
broken.  You said that a new electric hospital bed is a medical necessity because you are on oxygen and are an 
amputee. The Plan denied your request. The Plan says total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on December 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial for services 
that have been requested. The Plan denied your request. The Plan says you disenrolled from the optional 
supplemental plan effective January 31, 2023. Therefore, you are no longer eligible for the pre-service 
coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve maxillary partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5213) and mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve endocrinology care. You say that you want to continue seeing this doctor. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you 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 
endocrinology care to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs more physical therapy, 
occupational therapy, and speech therapy to help them improve. You also say that you have consulted with the 
enrollee's care team, and they believe additional therapy would be helpful for the enrollee. The Plan denied 
your request. The Plan says the requirements for continued admission in the SNF have not been met. 
 
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 pre-approve 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 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 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 pre-approve SNF care.