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

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that this item is necessary for your condition. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the providers depend on hospital staff to verify 
eligibility and obtain proper authorization. The Plan denied your request. The Plan says services from a non-
participating provider are not covered unless they are preauthorized. 
 
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 May 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services as originally billed provided 
from August 9, 2020, through August 14, 2020. 
 
You asked the Plan to pay for the inpatient hospital services as originally billed. You say that payment should 
be made for the services as billed. The Plan denied your request. The Plan says supporting documentation was 
not received to validate the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services as 
originally billed have been met. In this case, the Plan sent several requests for medical records to validate the 
services as billed. No record were returned.  Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital services as originally billed provided from August 9, 2020, through August 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on September 2, 2022 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with the copayment. The 
Plan denied your request. The Plan says this cost sharing was charged 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 outpatient diagnostic tests/Medicare-covered diagnostic radiology.  
 
You have been asked to pay a $250 copayment for CT scan. However, you are only being asked to pay $204.95 
which is less than the required amount. This item/service falls within the outpatient diagnostic tests/Medicare-
covered diagnostic radiology 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 computed 
tomography (CT) scan provided on September 2, 2022
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on September 
13, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were told you did not owe a 
copayment each time you asked. The Plan denied your request. The Plan says this cost sharing was charged 
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 $10 
copayment for physical therapy. 
 
You have been asked to pay a $10 copayment for physical therapy. This item/service falls within the physical 
therapy 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 physical therapy provided 
on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on July 30, 2021. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were told after every visit that you did 
not have a copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare-covered DME items.  
 
You have been asked to pay a coinsurance of $20.69, which is 20% of the allowed amount for DME ($103.45 
allowed x 20% = $20.69). This item/service falls within the Durable Medical Equipment 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 DME provided on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were not included in services that 
were performed by another provider. The Plan denied your request. The Plan says a corresponding observation 
code needs to be 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 looked at the file and the rules. The claim at issue was billed with an inpatient place of service code, 21. 
The records show that the enrollee was admitted under observation care on the date of service at issue. There is 
a more appropriate code available for the evaluation and management services provided during observation 
care. Based on this information, we decided that Medicare rules for coverage of the services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of 
service July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee goals are to be able to take care of 
themselves and be able to ambulate without pain, with the use of the least restrictive device. You say that the 
enrollee works so they need to be more safely functioning than they currently are to be able to go home and 
thrive. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee can receive the care they need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that you would like to continue care with your 
current out-of-network provider. The Plan denied your request. The Plan says services requested are available 
and can be safely performed by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI 
 
You asked the Plan to pre-approve the MRI. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that in the submitted records there is no 
record of an examination done on the thoracic or lumbar spine and no discussion concerning the need for MRI 
of the thoracic or lumbar spine. 
 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with a 
special radioactive agent, F-18 (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that you disagree with the denial. The Plan denied 
your request. The Plan says a PET/CT with F-18 fluoroestradiol is not included as a covered service. This type 
of PET scan is considered to be unproven and there are not enough studies to show this PET scan is better than 
the regular PET scan to manage the enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that evidence is not sufficient to determine that the 
results of NaF-18 PET imaging to identify bone metastases improve health outcomes of beneficiaries with 
cancer. 
 
 We looked at the file and Medicare rules. CMS shows that evidence is not sufficient to determine a NAF-18 
PET scan improves health outcomes of the enrollees cancer. It is not reasonable and necessary and not a 
covered service. Based on this information, we decided that Medicare rules for coverage of a PET scan have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission 
tomography (PET) scan with a special radioactive agent, F-18 (78815).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that you 
cannot afford this copayment, and were not told there would be one. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $75 copayment for a magnetic resonance imaging (MRI) scan. This item/service 
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 magnetic resonance imaging (MRI) scan provided on July 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the sales office stated for you to get a referral from the 
new provider and that it would be taken care of. The Plan denied your request. The Plan says there is no prior 
authorization on file for the 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 provided on July 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 13, 2018, 
to April 8, 2019. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says these inpatient hospital services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital services have been 
met. Medical records were not provided for the dates of service in question. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital services provided on September 13, 2018, to April 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the out-of-network mental health services 
provided on January 06, 2022, to June 23, 2022. 
 
You asked the Plan to reduce the coinsurance for the out-of-network mental health services. You say that you 
should only have a $30 copayment for these services. The Plan denied your request. The Plan says this cost 
sharing was charged 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 40% 
coinsurance for outpatient mental health care (out-of-network). 
 
You have been asked to pay 40% coinsurance for the out-of-network mental health services. This item/service 
falls within the outpatient mental health care (out-of-network) 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. The file shows that the Plan verified the provider is 
not a network provider. Therefore, we decided that the Plan does not have to reduce the coinsurance for the 
out-of-network mental health services provided on January 06, 2022, to June 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on April 11, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that you are appealing and requesting a 
reconsideration of the denied charges. The Plan denied your request. The Plan says the other insurance carrier 
has paid more that the full amount so there is nothing left for the Plan to pay. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. 
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has concluded 
that the enrollees insurance paid as the primary and have already paid more than the Medicare-allowed 
amount, which is $1,133.00 of the claim. As the secondary insurer, the Plan cannot be held responsible for the 
ambulance transport until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for ambulance transport provided on April 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for tooth extractions (D7140) provided on 
March 22, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
  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.  
 
You have been asked to pay a 50% coinsurance for tooth extractions. This item/service falls within the dental 
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 coinsurance for tooth extractions (D7140) 
provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pneumatic walking boot provided on 
August 18, 2022. 
 
You asked the Plan to waive the coinsurance for pneumatic walking boot. You say that you were told the 
insurance would cover the requested item 100%. The Plan denied your request. The Plan says this cost sharing 
was charged 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 20% 
coinsurance for Prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for pneumatic walking boot. This item/service falls within the 
Prosthetic devices and related 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 coinsurance 
for pneumatic walking boot provided on August 18, 2022.