Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation therapy and ultrasound therapy or 
waive the coinsurance for chiropractic manipulative treatment provided on April 13, 2022. 
 
You asked the Plan to pay for electrical stimulation therapy and ultrasound therapy and to waive the 
coinsurance for chiropractic manipulative treatment. You say that these healing techniques were critical for 
your healing process. The Plan denied your request. The Plan says other services performed by a chiropractor 
are not covered. The Plan also says that the coinsurance 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 Medicare-covered 
chiropractic services received out-of-network are responsible for 50% coinsurance at a specialists office. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
You have been asked to pay $19.51 (coinsurance) for the chiropractic manipulative treatment received out-of-
network. The chiropractic manipulative treatment falls within the Chiropractic 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. 
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation therapy and ultrasound therapy provided on April 
13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies (A6196 and A6219) provided on 
December 14, 2021. 
 
You asked the Plan to pay for the medical supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from February 
17, 2021, through December 2, 2021. The Plan says, per Medicare guidelines, the claim should be submitted 
for payment to Original Medicare. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 2, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical supplies 
(A6196 and A6219) provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick Urine Collection System. 
 
You asked the Plan to pre-approve Purewick Urine Collection System. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 Purewick Urine Collection System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation shows that you fell in the shower resulting in a soft 
tissue injury of the left hip. You have hip pain when ambulating. The records do not mention urinary 
incontinence. There are no peer-reviewed articles published in the medical literature specific to the PureWick 
system, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence 
to show the PureWick system to be an effective alternative in managing urinary incontinence. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick Urine Collection System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Purewick Urine Collection System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on January 25, 2022, by 
an OON provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you are requesting reconsideration 
stating you would like the Plan to reconsider the denial. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
 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 outpatient hospital services provided on January 
25, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Collagen Implantation for Urinary Incontinence (L8606, 
51715). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to collagen implant therapy, a skin test for 
collagen sensitivity must be administered and evaluated over a 4-week period. 
 
We looked at the file and Medicare rules. The records show no skin test for collagen sensitivity. Based on this 
information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Collagen Implantation for Urinary Incontinence (L8606, 
51715).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography provided on April 5, 
2022. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you weren't informed of the 
copayment. 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 $100 
copayment for diagnostic procedures and tests done in an outpatient hospital facility.  
 
You have been asked to pay $100 copayment for echocardiography. Echocardiography 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 echocardiography provided on April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was no 
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 laboratory services provided on April 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are a rural healthcare clinic and should be 
reimbursed at the Medicare rate for rural healthcare. The Plan denied your request. The Plan says services from 
non-participating providers are not covered unless 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 March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on April 8, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on December 8, 2021, by an 
OON provider. 
 
 
 You asked the Plan to pay for wound care supplies. You say that the enrollee has an approved admission in a 
nursing/rehabilitation facility as a resident, is insured under your Plan and is entitled to receive surgical 
dressings as a covered benefit. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
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 wound care supplies provided on December 8, 
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you are out-of-network, so no authorization was not 
obtained. You would like the claim processed as out-of-network. 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 x-
ray. We found no exception that would require the Plan to pay for the x-ray. Therefore, we decided that the 
Plan does not have to pay for the x-ray provided on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for an arthrocentesis, aspiration and/or injection, major joint or 
bursa (20610), a needle localization by x-ray (77002), a hymovis injection (J7322), a low osmolar contrast 
material of iodine concentration (Q9967) and a lidocaine injection (J2001) provided from January 28, 2022, to 
February 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an arthrocentesis, aspiration and/or injection, major joint or bursa, a needle 
localization by x-ray, a hymovis injection, a low osmolar contrast material of iodine concentration and a 
lidocaine injection. You say that you did not know the enrollee needed prior authorization for an out-of-
network provider. The Plan denied your request. The Plan says services require a prior authorization. 
 
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 arthrocentesis, aspiration and/or injection, 
major joint or bursa (20610), a needle localization by x-ray (77002), a hymovis injection (J7322), a low 
osmolar contrast material of iodine concentration (Q9967) and a lidocaine injection (J2001) provided from 
January 28, 2022, to February 4, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on March 28, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a duplex scan. You say that you did not obtain authorization for the duplex scan. 
You say that you are asking for reconsideration for the service. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
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 duplex scan provided on March 28, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (CMT); spinal, 3-4 
regions (98941), and mechanical traction therapy (97012) provided from April 20, 2022, to April 22, 2022. 
 
You asked the Plan to pay for the chiropractic care. You say that you were not told the authorization was 
denied before you went for your appointment. The Plan denied your request. The Plan says prior authorization 
was not obtained. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the mechanical traction therapy is not manual manipulation of the spine. Additionally, 
the manual manipulation of the spice that was performed, was not performed to correct subluxation. Therefore, 
we decided that the Plan does not have to pay for the chiropractic manipulative treatment (CMT); spinal, 3-4 
regions (98941), and mechanical traction therapy (97012) provided from April 20, 2022, to April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 28, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you thought this would be covered in 
full you weren't aware there would be a copayment. 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 $30 
copayment per day, per provider, for Medicare-covered lab services.  
 
You have been asked to pay $30 copayment for lab services. Lab services fall 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 laboratory services provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the initial observation care provided on 
February 9, 2019. 
 
You asked the Plan to waive the copayment for the observation care. You say that you are appealing this cost-
sharing. 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 $275 
copayment for observation services.  
 
You have been asked to pay the allowed amount of $134.31, which is less than the $275 copayment for 
observation services. The observation care 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 the initial observation care provided on February 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 3, 2022, and 
February 11, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that you received three treatments before being 
informed the chiropractic services were not a covered service. The Plan denied your request. The Plan says a 
PCP referral was not found to be listed on the claim and no authorization was found on file. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine and no authorization was 
found on file. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on 
February 3, 2022, and February 11, 2022.