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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an implantable loop recorder is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has no history of atrial 
fibrillation nor any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A recent 
randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by 
treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing 
stroke or systemic embolism among patients at high risk of stroke but without a known prior history of atrial 
fibrillation. An ILR is not medically appropriate and necessary for the enrollee'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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel (CPT 
code(s): 81404 and 81479) provided on September 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation submitted on appeal indicates the cardiovascular genetic screening panel was initiated by 
the laboratory and not by the member's treating physician. Therefore, we decided that the Plan does not have to 
pay for the cardiovascular screening/risk assessment panel (CPT code(s): 81404 and 81479) provided on 
September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 25, 2021, to December 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you believe the services should 
be covered by the Plan. The Plan denied your request. The Plan says you have been charged 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 $360 per 
day for days 1-5 and $0 per day after day 5 for each inpatient stay.  
 
The file shows that you were in the hospital from December 25, 2021, to December 28, 2021, for a total of 3 
days (there is no copayment for the discharge date). However, you have only been asked to pay $360 per day for the first 2 days of inpatient care. The total for your stay is $720 ($360 copayment x 2 days = $720). The 
inpatient care 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. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from December 25, 2021, to December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel (CPT 
code 81479) provided on March 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation submitted on appeal indicates the cardiovascular genetic screening panel was initiated by 
the laboratory and not by the enrollee's treating physician nor following a consultation or evaluation by the 
member's treating physician. The enrollee states they do not remember how they were contacted about the 
testing, but remembers receiving the test kit at their home, swabbing their cheek and sending it back. States the 
enrollee did not discuss it with their doctor and the enrollee's doctor did not order it. States the enrollee does 
not have any heart problems and does not see a Cardiologist. Reports the enrollee did not ever receive any test 
results and her doctor did not discuss any test results with the enrollee. Therefore, we decided that the Plan 
does not have to pay for the cardiovascular screening/risk assessment panel (CPT code 81479) provided on 
March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 You asked the Plan to pre-approve a power wheelchair. 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 power wheelchairs 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 a power wheelchair. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that you have a mobility limitation that significantly impairs his ability to participate in one or more 
mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. The documentation does not support that your mobility limitation 
cannot be sufficiently resolved by the use of an appropriately fitted walker or that your home provides adequate 
access between rooms, maneuvering space, and surfaces for use of the wheelchair that is requested. The 
documentation does not support that the use of the power wheelchair will significantly improve your ability to 
participate in MRADLs and that you will use it on a regular basis in the home. There is no objective physical 
examination with a gait evaluation, upper extremity and lower extremity function and other physical and 
mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a 
typical day. There are no objective exam findings of strength, endurance, range of motion, or coordination, 
presence of pain, or deformity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and psychotherapy provided on January 14, 
2021, to October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and psychotherapy. You say that the patient does not need a prior 
authorization. The Plan denied your request. The Plan says the services are not authorized because the provider 
and the facility are non-network provider who do not work with the Plan, and the member self-directed for 
care. The Plan also says that the member's primary care provider did not refer for services. 
 
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 an office visit and psychotherapy provided on 
January 14, 2021, to October 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided from July 19, 2021, through 
August 17, 2021. 
 
You asked the Plan to pay for incontinence supplies. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided by 
from July 19, 2021, through August 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a mental health telehealth visit provided on 
January 18, 2022. 
 
You asked the Plan to reduce the copayment for a mental health telehealth visit. You say that your copayment 
is reduced to $15 because you are in the Special Supplemental Benefits for the Chronically Ill (SSBCI) 
program. The Plan denied your request. The Plan says you have been charged 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 $30 
copayment for an outpatient mental health telehealth visit. The Plan contract also says that enrollees must pay a $15 copayment for an in-person outpatient mental health visit. 
 
According to the EOC, the $15 copayment under the Special Supplemental Benefits for the Chronically Ill 
(SSBCI) benefit category only applies to in-person mental health visits. You have been asked to pay a $30 
copayment for a mental health telehealth visit. A mental health telehealth visit falls 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 reduce the copayment for a mental health 
telehealth visit provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the replacement of a single lead 
defibrillator (32262) provided on November 11, 2021. 
 
You asked the Plan to reduce the copayment for the defibrillator lead replacement. You say that the doctor only 
replaced the battery in your pacemaker. The Plan denied your request. The Plan says you have been charged 
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 $350 
copayment for outpatient surgery at an ambulatory surgical center.  
 
According to Medicare, the billing code 32262 is for both the removal and replacement of a single lead 
defibrillator. You have been asked to pay a $350 copayment for the defibrillator lead replacement. The defibrillator lead replacement falls 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 reduce 
the copayment for the replacement of a single lead defibrillator (32262) provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
head provided on October 4, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that a Plan representative informed you 
that you would not have any copayments for appointments and tests. The Plan denied your request. The Plan 
says you have been charged 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 $250 
copayment for diagnostic and nuclear medicine radiological services, such as CT scans.  
 
You have been asked to pay $178.58, which is less than the $250 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the head provided on October 
4, 2021.  
 
Your complaint about the Plan representative giving misinformation about not having any copayments is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office visit provided on January 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office visit. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 visit provided on January 24, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehab facility stay provided 
from November 22, 2021, to December 2, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehab facility stay. You say that a staff member 
who coordinate's rehab services  advised you that it would be covered under your hospitalization. The Plan 
denied your request. The Plan says the copayment was applied 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 $295 
copayment for inpatient rehab facility stays.  
 
 You have been asked to pay $295 for the inpatient rehab facility stay. Inpatient rehabilitation facility stays fall 
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. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient rehabilitation facility stay provided from November 22, 2021, to December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on August 23, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the coding is incorrect and you 
should not have a copayment. The Plan denied your request. The Plan says you have been charged 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 $200 
copayment for CT, MRI, MRA, and SPECT scans.  
 
You have been asked to pay $140.36, which is less than the $200 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the thorax provided on August 
23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
August 19, 2021, to December 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that the services were 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on August 
19, 2021, to December 30, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you were informed there would not be a 
copayment for the service. The Plan denied your request. The Plan says you have been charged 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 an $85 
copayment per visit for services provided at an outpatient hospital facility.  
 
You have been asked to pay an $85 copayment for the ECG. The ECG 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 an electrocardiogram 
(ECG) provided on December 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a soft tissue ultrasound provided on 
October 4, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you paid your office visit 
copayment and was later billed for the ultrasound. The Plan denied your request. The Plan says you have been 
charged 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 an ultrasound. The Plan contract says that enrollees must pay a $45 copayment for a specialist 
office visit. The contract also says that if you receive additional services, additional cost sharing may apply. 
 
The record shows this claim was approved, and you have a cost sharing amount. According to the EOC, if you 
receive additional services during a specialist office visit additional cost sharing may apply. You have been 
asked to pay a $100 copayment for an ultrasound. An ultrasound 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 a soft tissue ultrasound provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays rendered on December 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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. The Plan does not list bitewing x-rays as a covered benefit. We looked at the file and the Plan's rules. The supplemental benefit with the Plan does not cover bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays rendered on December 8, 2021.