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

 
We decided that the Plan does not have to pre-approve placement of epidural leads. 
 You asked the Plan to pre-approve placement of epidural leads. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stimulator trials are only covered for certain 
indications. 
 
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 placement of epidural leads. Our 
reviewer says that the documentation does not support that the requested services are not medically necessary. 
Our physician reviewer found the enrollee has chronic low back pain. Imaging shows multi-level degenerative 
disc disease. There is no documentation of Physical therapy, Psychological evaluation or prior spine surgery. 
Therefore, the enrollee does not have an indication for a stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of epidural leads have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of epidural leads.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 14, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on April 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says medical records were not provided to support that you have tried and failed one of 
the Plan's step therapy drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided by 
your provider that shows you have tried one of the Plan's preferred drugs (Orthovisc, Synvisc, or Synvisc One), 
or any medical reasons that prevent you from using one of them. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on January 18, 2022, and February 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that the provider did not inform you they are not contracted 
with your plan. 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 office visits provided on January 18, 2022, and 
February 15, 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 diagnostic colonoscopy provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you were told to have 
this procedure so you thought it would 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 $325 
copayment for surgical services in an outpatient hospital facility.  
 
You have been asked to pay $325 copayment for diagnostic colonoscopy. Diagnostic 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 diagnostic colonoscopy 
provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit and x-ray provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit and x-ray. You say that you have never 
been charged for this in the past. The Plan denied your request. The Plan says the copayments applied are 
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 $35 
copayment for x-rays and $45 copayment for specialist visits.  
 
 You have been asked to pay $80 ($35 + $45) copayment for specialist office visit and x-ray. X-rays fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The specialist office 
visit falls within the Physician/Practitioner Services, Including Doctors 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 specialist office visit and x-ray provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861, E2377, E2311, 
E2313). 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that this power wheelchair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair (K0861, E2377, E2311, E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with single power 
option and accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with single power option and accessories. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair with single power option 
is medically necessary for individuals that require either power tilt or power recline. 
 
Review of the file shows that while the enrollee has a diagnosis of cerebrovascular accident, the enrollee is not 
high risk for pressure ulcer. The documentation does not support that the enrollee needs either power tilt or 
power recline. Since the requested power wheelchair is not a covered benefit, the requested accessories cannot 
be covered. This means the enrollee does not meet criteria for the requested item. Therefore, we decided that 
the Plan does not have to pre-approve a group three power wheelchair with single power option and 
accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services (97214). 
 
You asked the Plan to pre-approve the massage therapy services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services (97214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 29, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting a reconsideration stating it 
was medically necessary. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 March 29, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion provided on March 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the intravenous infusion. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
intravenous infusion. We found no exception that would require the Plan to pay for the intravenous infusion. 
The records provided for review do not show that intravenous infusion was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the intravenous infusion provided on March 31, 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 a guided epidural injection provided on February 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a guided epidural injection. You say that although you are out-of-network for 
this member's plan, the member cannot choose which radiologist reads the diagnostic tests. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained 
prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a guided epidural injection provided on February 
25, 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 specialist visit provided on June 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for specialist 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 specialist visit provided on June 7, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you were told services would be covered 
by insurance. You also say you were not told you would be charged out of pocket for the eye exam. The Plan 
denied your request. The Plan says the services received by a non-contracted provider in the plan services area 
were not for an urgent or emergent reason, were available to be provided in-network and were not authorized as 
required. 
 
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 ophthalmological services provided on April 20, 
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 a resin-based composite filling on tooth #21 (D2391) 
provided on March 29, 2022, and extractions of tooth #23 and 27 (D7140) and adding a tooth to an existing 
partial denture for tooth #23 and 27 (D5650) provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know these services were not 
covered. The Plan denied your request. The Plan says resin-based composite fillings (D2391), extractions 
(D7140), and adding a tooth to an existing partial denture (D5650) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite filling on tooth #21 (D2391) provided on March 29, 2022, and extractions of tooth #23 and 27 
(D7140) and adding a tooth to an existing partial denture for tooth #23 and 27 (D5650) provided on April 6, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88312, 88305) provided on April 7, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. 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 they were 
non-emergent and prior authorization was not obtained. 
 
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 (88312, 88305) provided on 
April 7, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 4, 
2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered in 
full. 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 $250 
copayment for each one-way Medicare- covered ground trip.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport 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 transport 
provided on June 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are on a fixed income 
and cannot afford the bill. 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 $200 
copayment for Medicare- covered ambulance benefits.  
 
You have been asked to pay $200 copayment for ambulance transport. Ambulance transport 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 transport 
provided on February 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in person mental health visit provided on 
March 21, 2022. 
 
You asked the Plan to waive the copayment for in person mental health visit. You say that usually you have 
telehealth visits where there is no copay, but due to circumstance out of your control you had to go in person, 
so you think this should be waived. 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 $25 
copayment per visit for individual therapy.  
 
 
 
 You have been asked to pay $25 copayment for in person mental health visit. In person mental health visits fall 
within the Outpatient Mental Health 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 in person mental health visit provided on March 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 29, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that you did not receive proper notice of the 
enrollee's benefit determination, hence the untimely submission. The Plan denied your request. The Plan says 
the claim was received on April 14, 2022, which is past the allowed 12 month timeframe. 
 
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 nursing facility care was not filed until April 14, 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 subsequent nursing facility care provided on March 29, 2021.