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

 
We decided that the Plan does not have to pre-approve wheelchair accessories and options. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is able to control the approved power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested. 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 requested services. Our physician reviewer found that the enrollee has primary 
progressive multiple sclerosis and is having trouble walking. She has weakness in the left upper extremity. Her 
right upper extremity is functional. The enrollee is able to cook and has an entirely functional right upper 
extremity. Therefore, an expandable controller is non medically necessary per Medicare rules.  
 
The file shows that a power seat elevation system and transfer assist extension were requested. These items are 
not primarily medical in nature. 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 requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories and options.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for immunoassay nonantibody laboratory 
testing provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for the laboratory testing. You say that you have had the same 
exact tests taken in 2020 without being charged a copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each out of network lab service for Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies.  
 
The records show in 2020 you were not enrolled in the same health plan, so cost sharing responsibilities may 
have changed. You have been asked to pay a $23.42 copayment for two out of network laboratory tests (11.71 
per test x 2 tests = 23.42) which is less than your contract allows. Laboratory testing 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 immunoassay nonantibody laboratory testing provided on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided January 21, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82728, 83540, 83550) provided January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 26, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the records support the procedure. The Plan 
denied your request. The Plan says the code shall not be reported separately. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 71045 is a column II code to column I code 32555. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 71045 
billed for date of service January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
December 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the secondary diagnosis code and DRG was not supported in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190 (CHRONIC OBSTRUCTIVE 
PULMONARY DISEASE WITH MCC). 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 pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that the review has determined that the records did not support J96.21 - acute and 
chronic respiratory failure with hypoxia - as used in this case. The appropriate DRG was DRG 192: CHRONIC 
OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
4, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the copayment would put you 
in a financial strain, and you are unable to afford this. 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 $325 
copayment for covered ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. Ambulance services falls within the 
Ambulance 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 ambulance 
services provided on March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve a cochlear implant. You say that the requested cochlear implant is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
cochlear implant. 
 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 a cochlear implant. Our reviewer says 
that the enrollee does not meet criteria for the requested cochlear implant. Our physician reviewer found based 
on available clinical documentation, the requested services for right-sided cochlear implantation do not meet 
criteria for Medicare coverage. Audiometric results showed that the right-sided AzBio score was 10% in quiet, 
but the left-sided score was 69% in quiet and 43% binaurally at +10 dB SNR, so the enrollee does not appear to 
meet the audiologic criterion. In summary, the requested services for right-sided cochlear implantation do not 
meet Medicare 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 a cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine infusions and inpatient hospital services for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that current medical literature indicates that this service is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
Ketamine infusions and inpatient hospital services are not medically reasonable and necessary. Ketamine 
infusions are not FDA-approved for the enrollees diagnosis. The use of Ketamine for migraines is not readily 
supported in the compendia for use in the prevention/management of chronic migraine. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ketamine infusions and inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim crown  further treatment or completion of 
diagnosis necessary prior to final impression (D2799) provided April 4, 2022. 
 
You asked the Plan to pay for an interim crown. You say that this was a special circumstance. The Plan denied 
your request. The Plan says this service is not covered under your benefits. 
 
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 an interim 
crown  further treatment or completion of diagnosis necessary prior to final impression (D2799) provided 
April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cranial prosthesis provided on February 10, 2022. 
 
You asked the Plan to pay for the cranial prosthesis. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says a cranial prosthesis (wig) is not covered by 
Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the cranial prosthesis 
provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
power features can be controlled using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a past medical history of CVA with spastic hemiplegia and functional 
impairments, power mobility device bound. Clinical documentation shows that the enrollee has difficulty with 
coordination of upper limbs along with spasticity of dominant side and has power functions thus coverage 
determination criteria have been met for an expandable controller system. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an expandable control system.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 18, 2022. 
 You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is statutorily 
excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel at issue includes the FANCC gene. Panels of tests 
that include this gene are statutorily excluded from coverage. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the gene panel testing provided on February 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the pelvis provided on 
March 9, 2022. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you were expecting to pay a $45 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for an ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce 
the copayment for an ultrasound of the pelvis provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no report of syncope or documentation to support ventricular arrhythmia. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on August 
27, 2021. You asked the Plan to pay for the services provided. You say that the records illustrate the need for services. 
The Plan denied your request. The Plan says there is a more appropriate code to describe the 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. 
 
The file shows that CPT code 99310 was billed for the evaluation and management services provided in an 
assisted living facility. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services provided on August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 2, 2020. 
 
You asked the Plan to pay for the lab services. You say that you were not provided the active policy plan until 
the time limit expired. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until March 18, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on March 31, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not have the money for the 
copay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a computed tomography (CT) scan of the abdomen and pelvis provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 84100) provided 
October 13, 2020. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 82728, 83540, 83550, 84100) provided October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cyst removal provided on February 25, 
2022. 
 
You asked the Plan to reduce the copayment for the cyst removal. You say that you were not told about the 
facility fee. 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 $120 
copayment for each outpatient hospital facility visit.  
 
The record shows you received the services at an outpatient hospital. You have been asked to pay a $120 
copayment for the cyst removal. Cyst removal falls within the Outpatient Surgery, Including Services Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for the cyst removal provided on February 25, 2022.