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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on October 
19, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you never went to a 
hospital, and no one told you the copayment would be this high. The Plan denied your request. The Plan says 
the provider billed for the service that as rendered in an outpatient hospital. Therefore, the proper copayment 
was applied for the service that was rendered. 
  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 Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $295 copayment for the outpatient surgery. The outpatient surgery falls within 
the Outpatient Surgery and Other Medical 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 
outpatient surgery provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control for a power wheelchair (E2331). 
 
You asked the Plan to pre-approve the attendant control. You say that the attendant controller is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is covered in place of a 
beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable 
to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but 
is able to operate a power wheelchair. 
 
We looked at the file and Medicare rules. The requested chair already includes a beneficiary-operated joystick. 
Based on this information, we decided that Medicare rules for coverage of the attendant control have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an attendant control for a power 
wheelchair (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Office Visit provided on October 6, 2020 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office Visit. You say that the doctor saw the patient two weeks prior to an out-
of-network emergency room visit. The Plan denied your request. The Plan says prior authorization is required 
for an out-of-network office 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 an Office Visit provided on October 6, 2020 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalomatrix skin substitute. 
 
You asked the Plan to pre-approve Hyalomatrix skin substitute. The Plan denied your request. The Plan says 
the requested Hyalomatrix skin substitute is not covered as it is experimental. 
 
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 pre-approve Hyalomatrix skin substitute. Our 
reviewer says that the requested Hyalomatrix skin substitute is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that Hyalomatrix is considered experimental and is not 
covered. The requested Hyalomatrix skin substitute at issue in this case is not medically reasonable or 
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 Hyalomatrix skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyalomatrix skin substitute.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you need SNF services. The Plan denied your 
request. The Plan says SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no skilled nursing needs, but 
you do have skilled therapy needs.  However, you do not require skilled therapy on a daily basis in an inpatient 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit provided on November 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hospital visit. You say that you are in the process of becoming a contracted 
provider and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 hospital visit provided on November 5, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of a lower 
extremity. 
 
You asked the Plan to pre-approve the MRA. You say that the records provided support the need for an MRA. 
The Plan denied your request. The Plan says they did not receive physical exam results that show a reason the 
requested study is needed. 
 
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 pre-approve the MRA. Our reviewer says that the 
requested MRA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has had bilateral leg pain and numbness for 2 weeks, especially at night. Examination 
findings included normal spine, no cyanosis, edema, tenderness, or deformities in legs, no motor/sensory 
deficits, skin was dry and warm, and without rashes, ulcers, or pallor. An MRA is not sufficiently supported in 
the provided documentation. The examination findings did not show the physician examined pulses or that an 
ABI was completed. There was not a history of symptoms suggestive of claudication to confirm some degree 
of obstruction/stenosis of the arteries in the legs. There was no documentation of formal nerve testing or provocative spine testing (straight leg, etc.) to rule out neurological source of the symptoms. 
 
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 MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance angiography (MRA) of a lower extremity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee needs to go to rehab in order to get back on her feet 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological Services provided on September 15, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological Services. You say that the member could not choose an in-
network optometrist since no other providers were allowed in the facility and providers have no prior 
knowledge of which patients they will be required to see. The Plan denied your request. The Plan says the 
required 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 Ophthalmological Services provided on 
September 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 22, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
this was a wellness visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided, because other issues were discussed during the visit you were assessed a copayment. 
 
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 $15 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $15 copayment for an office visit. 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 office visit provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on December 28, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital clinic visit. You say that you would like the claim to be 
reprocessed for payment and it was medically necessary to treat the enrollee. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the outpatient hospital clinic visit provided on 
December 28, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from February 
19, 2021, to February 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF stay. You say that you would like for the claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no approved authorization for the dates of service. 
  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 skilled nursing facility (SNF) stay provided from 
February 19, 2021, to February 26, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (64495). 
 
You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level(s). The Plan denied your request. The Plan says the injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) do not meet the 
Medicare LCD guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; third and any additional level(s). Our reviewer says that injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) is not medically 
necessary. Our physician reviewer found according to the coverage criteria, "One to two levels, either unilateral 
or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal."  In this case, the provider has requested three levels. The review has determined that the enrollee does 
not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and 
any additional level(s) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) 
(64495).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an anoscopy and dilation performed on 
September 30, 2021. 
 
You asked the Plan to waive the copayment for the anoscopy and dilation. You say that you were not informed 
of any copayment at the time of 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 a $360 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $360 copayment for the anoscopy and dilation. The anoscopy and dilation falls within the Outpatient Surgery and Other Medical 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 anoscopy 
and dilation performed on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Prolia injections provided on June 1, 2021, 
and November 19, 2021. 
 
You asked the Plan to waive the coinsurance for Prolia injections. You say that you should have been billed 
within a month. You also say you use your medical for tax credits and can no longer use these claims as 
deductions for 2021. 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 20% 
coinsurance for part B drugs.  
 
 You have been asked to pay $237.24, which is 20% of the allowed amount for a Prolia injection on June 1, 
2021 ($1,186.20 allowed amount x 20% coinsurance = $237.24). You have also been asked to pay $250.20, 
which is 20% of the allowed amount for a Prolia injection on November 19, 2021 ($1,251 allowed amount x 
20% coinsurance = $250.20). Prolia injections 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 coinsurance for Prolia injections provided on June 1, 2021, 
and November 19, 2021.  
 
Your complaint about receiving the bill later than expected 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided August 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 code G0483 is not supported in the medical record. Specifically, a valid, signed physician 
order for this service was not included in the records. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (G0483) provided August 19, 2021.