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

 
We decided that the Plan does not have to waive the cost share for the imaging guidance and radiation therapy 
provided on November 16, 2021, and December 10, 2021. 
 
You asked the Plan to waive the cost sharing for the imaging guidance and radiation therapy. You say that you 
were told you would only be responsible for $15 per treatment. The Plan denied your request. The Plan says the 
cost share amount 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 you must pay a $15 
copayment for x-ray services and 20% coinsurance for therapeutic radiology. 
 
You have been asked to pay a total of $189.50 for the imaging guidance and radiation therapy.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
November 16, 2021 Imaging Guidance  $66.32 $15 $15 
November 16, 2021 Radiation Therapy $398.76 20% coinsurance $79.75 
December 10, 2021 Imaging Guidance $66.32 $15 $15 
December 10, 2021 Radiation Therapy $398.76 20% coinsurance $79.75 
TOTAL:    $189.50 
 
The imaging guidance and radiation therapy 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 cost sharing for the imaging guidance and 
radiation therapy provided on November 16, 2021, and December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole DR tablets.
You asked the Plan to pre-approve Pantoprazole. You say that the Pantoprazole is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole DR tablets.
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the therapeutic parenteral drug. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you 
signed a treatment plan on November 24, 2021 acknowledging that you would be financially responsible for 
the out-of-pocket expense for the therapeutic parenteral drug. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the 
therapeutic parenteral drug (D9610) provided on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee requires ongoing acute care services. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthesis. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a new prosthesis cannot be approved at this time. 
 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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested items exceed the patient's medical need as the documentation does not support that this 
patient is a K3 ambulator. She was recently approved for a Group 2 power wheelchair for MRADLs in the 
home due to  patient's inability to ambulate, need for max assist with transfers, and stage 2 pressure ulcers. The 
documentation does not support that the patient requires a K3 level Flex Walk system therefore this request is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a new prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130) and eight 
additional simple extractions (D7140 x8) provided on December 16, 2021. 
 
You asked the Plan to pay for the maxillary immediate denture and additional extractions. The Plan denied 
your request. The Plan says the maxillary immediate denture is not a covered service under your Plan. The Plan 
says that your extractions benefit was exhausted on this same date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary immediate denture (D5130) 
is not among those covered under this benefit. The contract says that extractions are limited to two procedure 
codes per calendar year. The record shows that you received 10 extractions on December 16, 2021, two of 
which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the maxillary immediate denture (D5130) and eight additional simple 
extractions (D7140 x8) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chest x-ray, a computed tomography 
(CT) scan of the chest, and a CT scan of the abdomen and pelvis provided on October 17, 2021, and ultrasonic 
guidance for a biopsy needle placement provided on October 21, 2021. 
 
You asked the Plan to waive the coinsurance for a chest x-ray, the CT scans, and the biopsy needle placement.. 
You say that your father was wrongly signed up for a managed Medicare plan. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay 30% coinsurance for out-of-network basic radiological services, including x-rays at a freestanding 
radiological facility. The Plan contract also says that enrollees must pay 30% coinsurance for out-of-network 
advanced imaging services, including CT scans and ultrasounds at a freestanding radiological facility. 
 
The enrollee has been asked to pay 30% coinsurance for a chest x-ray, the CT scans, and the biopsy needle 
placement. 
 
Date of Service Code Allowed Amount 30% Coinsurance 
October 17, 2021 71250 $50.74 $15.22 
October 17, 2021 74176 $86.41 $25.92 
Total   $41.14 
October 17, 2021 71045 $9.14 $2.74 
Total   $2.74 
October 21, 2021 10160 $98.04 $29.41 
October 21, 2021 76942 $31.54 $9.46 
Total    $38.87 
 
A chest x-ray, the CT scans, and the biopsy needle placement falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a chest x-ray, a computed tomography (CT) scan of the chest, and a CT scan of the abdomen 
and pelvis provided on October 17, 2021, and ultrasonic guidance for a biopsy needle placement provided on 
October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 23, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you do not need a primary care physician 
referral in your contract. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on November 23, 2021, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for pulmonary services provided from 
September 7, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayments for the pulmonary services. You say that you were not informed 
of any copayments at the times 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 $20 
copayment for each pulmonary function test.  
The file shows that the Plan has agreed to waive the copayments for the pulmonary services provided on 
September 7, 2021, and September 24, 2021. You have been asked to pay a $20 copayment for the pulmonary 
function test provided on September 9, 2021. The pulmonary 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 copayments 
for pulmonary services provided from September 7, 2021, to September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic 
x-ray (D0330) provided by a participating provider on January 17, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and a panoramic x-ray. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0150 and 
D0330 has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and a panoramic x-ray when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. D0150 and D0330 were previously provided on January 11, 2022. 
Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and 
a panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), and a panoramic x-ray (D0330) provided by a participating provider 
on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and two or more power seating system motors, (E2311) harness for upgrade to 
expandable controller (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please reconsider the documentation 
provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. 
The Plan denied your request. The Plan says the upgraded electronics are 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 the for upgraded electronics. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not require a ventilator, or non-proportional input devices 
(e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control 
devices), other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control), or an attendant control. The enrollee has power options on the wheelchair, but the 
enrollee does not need to control the power options through a joystick. The enrollees right upper extremity 
strength   supports that the patient can control any power options through their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and two or more power seating system motors, (E2311) harness for upgrade to expandable controller 
(E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are not enough studies to show that this brace is better than standard treatment. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found although records from the device manufacturer/vendor argue medical necessity of the requested device, 
no records from the enrollees actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollees condition. Current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro powered arm brace for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 
based on the documentation submitted, they have determined that the services rendered to the member are not 
urgent or emergent, nor were they approved in advance by a 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 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 domiciliary or rest home visit provided on 
November 11, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for remote physiologic monitoring treatment 
management services provided on October 12, 2021. 
 
You asked the Plan to waive the copayment for remote physiologic monitoring treatment management services. 
You say that you are questioning each $35 charge for each pulmonary rehabilitation session showing on your 
claim form. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician specialist services.  
 
You have been asked to pay a $35 copayment for remote physiologic monitoring treatment management 
services. Remote physiologic monitoring treatment management services falls within the physician/practitioner 
services, including doctor's office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for remote physiologic monitoring treatment management services provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dorsal column stimulator. 
 
You asked the Plan to pre-approve a dorsal column stimulator. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation unless specific 
conditions are met. 
 
 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 dorsal column stimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found according to 
Medicare, an implanted dorsal column or depth brain stimulator can be considered if the implantation 
stimulator is used only as a last resort or for enrollees with chronic intractable pain; other treatment modalities 
(pharmacological, surgical, physical or psychological therapies) have been tried and did not prove satisfactory, 
or are judged to be unsuitable or contraindicated for the given enrollee; enrollees have undergone careful 
screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must 
include a psychological and physical evaluation. In this case, the documentation provided does not indicate that 
the enrollee has been evaluated by a psychiatric provider. 
 
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 dorsal column stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a dorsal column stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics (L4361) provided on 
January 20, 2022. 
 
You asked the Plan to waive the coinsurance for the foot orthotics. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied correctly 
based on the services provided. 
 
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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the foot orthotics (allowed amount is $273.15 x 20% = 
$54.63). Foot orthotics falls within the Durable medical equipment (DME) 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 foot orthotics (L4361) provided on January 20, 
2022.