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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that you do not agree with the 
denial and are requesting reconsideration. The Plan denied your request. The Plan says there is one requested 
power option on this wheelchair (tilt), there is not a medical need to control this power option through the 
joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
one power seating system motor (E2310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the inpatient hospital services provided from May 4, 
2020, to June 26, 2020. 
 
You asked the Plan to pay more for the inpatient hospital services. You say that you have provided medical 
records to support payment at the original amount requested. The Plan denied your request. The Plan says 
despite several requests, you have not provided the needed itemized bill for this hospitalization. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to determine the appropriateness of cost 
outlier payments, the itemized bill is required in order to ensure proper medical necessity and coding 
requirements have been met.  The Plan has requested this itemized bill from your organization multiple times 
with no response.  Without this itemized bill, conformance with Medicare coverage and coding guidelines 
cannot be determined. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay more for the inpatient hospital services provided from May 4, 2020, to June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental cone beam CT scan (D0634). 
 
You asked the Plan to pre-approve cone beam imaging. You say that you have a spot on your tooth and need 
the imaging your dentist requested. The Plan denied your request. The Plan says the requested service, 
represented by code D0364, is not listed as a covered dental code. The Plan states this dental service is 
excluded from coverage and there are no exceptions that would allow the Plan to cover dental code D0634. 
 
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 pre-approve a 
dental cone beam Computed Tomography (CT) scan (D0634).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the mammogram. You say that the test is only diagnostic due to 
your history of breast cancer and you should not have to pay. 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 $35 
copayment for basic imaging services.  
 
You have been asked to pay a $35 copayment for the mammogram. The mammogram 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 diagnostic mammogram provided on February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an epidural provided on December 1, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this procedure helps you to 
function in daily living, but you are on a fixed income. The Plan denied your request. The Plan says the 
copayment amount you are being charged 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 $275 
copayment for in-network outpatient surgery at an outpatient hospital facility. An epidural is considered to be 
an outpatient surgical procedure; therefore, the outpatient surgery copayment applies to this claim. 
 
You have been asked to pay $275 copayment for outpatient surgery. Outpatient surgery 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 waive the copayment for an epidural provided on 
December 1, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for treatment room services billed by the hospital on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for treatment room services. You say that you were never seen in 
the hospital. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not submit documentation supporting the enrollee was seen at a 
hospital facility to be charged for a treatment room. Therefore, we decided that the Plan has to waive the 
copayment for treatment room services on November 17, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
5, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you do not know why the visit was 
not covered. 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 $18 
copayment for each specialist visit.  
 
The file shows that the Plan reprocessed the claim to reflect the proper copayment. Therefore, you have been 
asked to pay an $18 copayment for the office visit. The office visit falls within the Physician/Practitioner 
Services, Including Doctor's 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 a specialist office visit provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system and phone holder. 
 
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 covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system and phone holder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6065) for teeth # 12 and 
14, pontic (D6245) for tooth # 13, and retainer crown (D6740) for tooth # 15. 
 
You asked the Plan to pre-approve the dental services. You say that your benefit is unlimited. You say that the 
services should be covered. You also say that you do not have any dental history with this coverage. The Plan 
denied your request. The Plan says the frequency limit has been exceeded. 
 
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 and the services are listed as covered, 
up to a maximum of 10 units per fixed bridge unit are covered. The record shows that the Plan approved units 
for teeth # 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11, thus exhausting the benefit. Therefore, we decided that the 
Plan does not have to pre-approve implant supported crowns (D6065) for teeth # 12 and 14, pontic 
(D6245) for tooth # 13, and retainer crown (D6740) for tooth # 15.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 5 additional physical therapy visits. You say that the 5 additional physical 
therapy visits are medically necessary. The Plan denied your request. The Plan says that the 5 additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 5 additional physical therapy visits. Our 
reviewer says that the 5 additional physical therapy visits are medically necessary. Our physician reviewer 
found Parkinson's disease is a neurodegenerative disease in which the gait dysfunction would benefit from both 
a skilled therapist from a treatment standpoint as well as from a maintenance standpoint. 10 treatment physical 
therapy sessions would be consistent with evidence-based treatment guidelines. The 5 additional physical 
therapy visits are 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 5 additional physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 5 additional physical therapy (PT) visits.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 20, 2022. 
 
You asked the Plan to pay for dental services. You say that you were having gum issues and a broken tooth. 
You say that this provider was close to your home. The Plan denied your request. The Plan says the rendering 
dentist is out-of-network. 
 
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 dental 
services provided by an out-of-network provider on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a steroid injection performed on February 
2, 2022. 
 
You asked the Plan to reduce the copayment for the injection. You say that your copayment should only be $30 
for the office visit. 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 $195 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay a $195 copayment for the injection. The injection is considered a surgical 
procedure in nature, and falls within the Outpatient Surgery, Including Service 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 a steroid injection performed on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81235 provided on 
March 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that specific diagnosis codes support medical 
necessity of codes 81206 and 81235. 
 
We looked at the file and Medicare rules. Review of the file shows that these services were billed with 
diagnosis code C18.6 (Malignant neoplasm of descending colon). This diagnosis code is not listed as one that 
makes codes 81206 or 81235 medically necessary. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded 81206 and 81235 provided on March 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 X 
8) and home health skilled nursing visits (CPT code G0299 X 5). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found the documentation does not support that the member requires additional skilled nursing services 
or skilled rehabilitation services to provide treatment that is medically necessary. The member does not require 
additional skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in 
order to improve the members condition, perform a maintenance program to maintain the members condition 
and/or prevent deterioration. The member has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits (CPT code G0151 X 8) and home health 
skilled nursing visits (CPT code G0299 X 5).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission to be associated with left 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve inpatient hospital admission. The Plan denied your request. The Plan says 
there is no documentation provided to support the expectation the enrollee will require a greater than two 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient services are met in this 
case. Our physician reviewer found the provided documentation did not reveal the enrollee being unstable or 
having high risk factors to expect the enrollee to require hospital services that would likely cross two midnights 
related to this typically ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital admission to be associated with left shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for arthrocentesis, radiology services and 
injection used provided on March 1, 2022. 
 
You asked the Plan to waive the cost share for arthrocentesis, radiology services and injection. You say that the 
charges should be covered. The Plan denied your request. The Plan says the cost sharing 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 20% 
coinsurance for all other Medicare-covered Part B drugs, $115 copayment for Medicare covered radiological 
diagnostic services, not including x-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic) and a $25 copayment for a specialist office visit. 
 
You have been asked to pay a total of $140.24 for arthrocentesis, radiology services and injection. The 
arthrocentesis falls within Physician/Practitioner Services, Including Doctors Office Visits benefit category. 
The radiology services fall within Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The injection falls within the Medicare Part B Prescription Drugs benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for arthrocentesis, radiology services and injection used provided on 
March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on 
February 12, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were not informed of any 
copayments for ultrasounds. 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 ultrasounds.  
 
You have been asked to pay a $100 copayment for the ultrasound. The 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 an abdominal ultrasound provided on February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that since this was related to 
COVID-19 this should 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 $45 
copayment for each in-person specialist visit. 
 
You have been asked to pay $45 copayment for a specialist office visit. Specialist office visits fall 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 provided on December 8, 2021.