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

We decided that the Plan does not have to pre-approve custom orthopedic shoes and inserts to be rendered by
the out-of-network (OON) provider.
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested items.
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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve custom
orthopedic shoes and inserts to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #24.
You asked the Plan to pre-approve endodontic therapy. The Plan denied your request. The Plan says the service
is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 pre-approve
endodontic therapy for tooth #24.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory blood pressure monitoring and the
noninvasive ear or pulse oximetry for oxygen saturation provided on September 6, 2019.
You asked the Plan to pay for the ambulatory blood pressure monitoring and the noninvasive ear or pulse
oximetry for oxygen saturation. You say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
Code 94761 has a status indicator of "T". A status indicator of T means that this service is always bundled into
another payable physician service billed the same day by the same provider. This means that this code is not
separately payable. The records do not show that this monitor is requested in the setting of home dialysis
services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood
pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this
item in this situation. Therefore, we decided that the Plan does not have to pay for the ambulatory blood
pressure monitoring and the noninvasive ear or pulse oximetry for oxygen saturation provided on September 6,
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the specialist office visits, the x-rays, and
the Part B drug provided from March 1, 2021, and April 15, 2021.
You asked the Plan to reduce the copayments for the specialist office visits, x-rays, and the Part B drug. You
say that the Plan is not paying enough for the services. The Plan denied your request. The Plan says you have
been asked to pay the correct cost-sharing amount.
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 services obtained from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as
permitted by Medicare rules), a $15 copayment each Medicare-covered standard x-ray service, and 20%
coinsurance for each Medicare-covered Part B drug.
You have been asked to pay a total of $152.35 for the specialist office visits, x-rays, and the Part B drug. The
specialist office visits fall within the "Physician/Practitioner Services Including Doctor's Office Visits" benefit
category. The x-rays fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies"
benefit category. The Part B drug falls within the "Medicare Part B Prescription Drugs" benefit category. See
chart below.
Date of Service Service Allowed Amount Copayment/Coinsurance Member
Liability
March 1, 2021 Specialist office
visit
$52.65 $40.00 $40.00
March 1, 2021 X-ray $26.69 $15.00 $15.00
March 25, 2021 Specialist office
visit
$119.96 $40.00 $40.00
March 25, 2021 Part B drug $11.76 20% $2.35
April 15, 2021 Specialist office
visit
$55.76 $40.00 $40.00
April 15, 2021 X-ray $28.35 $15.00 $15.00
Total $152.35
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 copayments for the specialist office visits, the x-rays, and the Part B drug
provided from March 1, 2021, and April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need these items. The Plan denied your
request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that you
are not part of an active rehabilitation program.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under
certain medical 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 the requested services. Our physician
reviewer found that you have severe lumbar spinal stenosis from L2-L3 to L4-L as shown on magnetic
resonance imaging (MRI) and computed tomography (CT) scans. You previously had an epidural steroid
injection on May 6, 2 021, which gave you greater than 80% pain relief for several months. You have also tried
physical therapy in the past. Your physician states that you will be doing a home exercise program. The records
show that you meet the coverage criteria. Therefore, the requested service is medically reasonable and
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 requested services have been met. Therefore, we decided that the Plan has to
pre-approve an epidural steroid injection.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June
24, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are not payable 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 codes 80307 and G0483 are not supported in the medical record. Specifically, the place of
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was
obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for
the drug testing coded 80307 and G0483 provided on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy with
ultrasound guidance provided on August 10, 2021.
You asked the Plan to waive the copayment for the fine needle aspiration biopsy with ultrasound guidance.
You say that you were never informed there would be a separate copayment for the imaging service. The Plan
denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 diagnostic procedures and tests, including sounds, at all locations of service.
You have been asked to pay a $100 copayment for the fine needle aspiration biopsy with ultrasound guidance.
The fine needle aspiration biopsy with ultrasound guidance falls 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
the fine needle aspiration biopsy with ultrasound guidance provided on August 10,2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a neurobehavioral status exam provided on
August 20, 2021.
You asked the Plan to waive the copayment for a neurobehavioral status exam. You say that you have never
been from this facility in the past and disagree with the charges. The Plan denied your request. The Plan says
the claims were processed correctly and you are being charged the correct amount.
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 $50
copayment for outpatient hospital services.
The record shows that you received a neurobehavioral status exam at an outpatient hospital facility on August
20, 2021. Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for a neurobehavioral status exam. A neurobehavioral status
exam falls within the outpatient hospital services benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for a neurobehavioral status exam provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for future spinal injection procedures.
You asked the Plan to waive the copayments for future spinal injection procedures. You say that you need to
have these injections every 90 days and you cannot afford a $350 copayment each time. The Plan denied your
request. The Plan says you will be assessed the applicable copayment each time you have this service.
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 $350
copayment for outpatient surgery.
You have been asked to pay a $350 copayment for future spinal injection procedures. These spinal injection
procedures fall within the outpatient surgery 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 copayments
for future spinal injection procedures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the present setting where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure
(CPAP) device.
You asked the Plan to pre-approve CPAP device. You say that the enrollee uses the machine 7 to 9 hours every
night and it is medically necessary to have a functional PAP machine. The Plan denied your request. The Plan
says the denial of authorization for continued use of this device is correct, because there is no documentation of
whether the enrollee's symptoms have improved with use of this device and there does not seem to be any re-
evaluation outside of a review of past medical diagnoses.
The Plan follows Medicare rules. Medicare rules state that continued use of a CPAP device after 3 months may
be covered if certain 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 CPAP device. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested continued use of a CPAP device. Our
physician reviewer found the records indicate that there has been no discussion of whether obstructive sleep
apnea symptoms have improved or not. It is also unclear if the enrollee went for an in-person assessment.
There does not seem to be any re-evaluation of any kind outside of a review of past medical diagnoses; none of
which address the obstructive sleep apnea's current state. A CPAP titration study was performed on November
4, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued use of a continuous positive airway pressure (CPAP) device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on August 10, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. The Plan denied your request. The
Plan says this service is not included on your plan benefit schedule and is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 the
comprehensive periodontal evaluation (D0180) provided on August 10, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the emergency department services
provided on July 29, 2021, through August 3, 2021.
You asked the Plan to waive the cost sharing for the emergency department services. You say that you would
like reconsideration because the services rendered were medically necessary. The Plan denied your request.
The Plan says this claim has processed 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 $90
copayment for emergency department visits and a $100 copayment for the outpatient diagnostic test.
You have been asked to pay a $90 copayment for the emergency department services and a $53 copayment for
the outpatient diagnostic test. The Medicare allowed amount for the diagnostic test is lower than your
copayment, so you have been asked to pay less than your contracted amount for this service. 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 rules also say that Medicare Part B generally does not pay for drugs that are usually self-administered by
the patients who take them. Benefits for the self-administered drugs may be available under Medicare Part D.
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal
rights. Therefore, we decided that the Plan does not have to waive the cost sharing for the emergency
department services provided on July 29, 2021, through August 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the computed tomography (CT) scan of the
abdomen and pelvis you had at an outpatient hospital facility on May 21, 2021.
You asked the Plan to reduce the copayment for the CT scan. You say that the copayment for this service is
usually $150. You stated that it is not reasonable for you to have to leave the hospital to get a lower copayment
for this service. The Plan denied your request. The Plan says that you were charged this copayment 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 advanced imaging services at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the CT scan. The facility where you received this CT scan is
considered an outpatient hospital facility, so the CT scan falls within the advanced imaging services at an
outpatient hospital facility 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 the
computed tomography (CT) scan of the abdomen and pelvis you had at an outpatient hospital facility on May
21, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on June 28, 2021
You asked the Plan to pay for the dental service. You say that your dental insurance covers up to $1,000. You
say that you advised you only wanted the tooth that had fallen out to be put back in. You say that they took 2
different sets of x-rays. You say that the bill was adjusted from $1,100 to $963. You also say that a few months
later you were advised you were responsible for the full amount of $1,100. The Plan denied your request. The
Plan says that the complete series x-ray is not listed as a covered service. The Plan also says that accurate
information was given when you called to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete
series x-ray (D0210) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (81479) provided
on May 6, 2021.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing is not
a Medicare covered benefit.
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 cardiovascular risk assessment testing.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found there is no evidence to support this testings role in this member's
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 the cardiovascular risk assessment testing have not been met. Therefore, we
decided that the Plan does not have to pay for the cardiovascular risk assessment testing (81479) provided on
May 6, 2021.