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

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation system (0408T) and generator, cardiac contractility modulation (C1824). 
 
You asked the Plan to pre-approve these services. You say that the enrollee's life is at risk due to heart pumping 
inefficiently. The Plan denied your request. The Plan says that the Medicare guidelines say that this item or 
service is not medically necessary because a scientific assessment of the technique has not been completed and 
its safety and efficacy has not been established. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. While clinical 
studies led to FDA approval in 2019, cardiac contractility modulation (CCM) remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. 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 insertion or replacement of permanent cardiac contractility modulation system (0408T) 
and generator, cardiac contractility modulation (C1824).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on February 8, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a drug test provided on February 8, 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 a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you are not able to operate a power 
wheelchair. The Plan denied your request. The Plan says the records indicate you are not able to operate a 
power scooter safely. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) is covered if the 
beneficiary is able to safely transfer to and from a POV, operate the tiller steering system, and maintain 
postural stability and position while operating the POV in the home. The beneficiary's mental capabilities (e.g., 
cognition, judgment) and physical capabilities (e.g., vision) must also be sufficient for safe mobility using a 
POV in the home.  
 
We looked at the file and Medicare rules. The submitted medical records indicate that you are not able to safely 
operate a power scooter due to episodes of gout. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denied skilled nursing care visit performed by a non-
contracted provider was denied because non-contracted providers are not covered under open access 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 subsequent nursing facility care provided on 
January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit on January 21, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told there would 
be no copayment. The Plan denied your request. The Plan says the copayment 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 you must pay a $45 
copayment per visit to a specialist.  
 
You have been asked to pay a $45 copayment for your specialist office visit. Specialist Office Visits fall within 
the Physician/Practitioner Services, including doctors 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 a specialist office visit on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Complex Chronic Care Management Services provided on 
July 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Complex Chronic Care Management Services. You say that you would like to 
appeal the denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Complex Chronic Care Management Services 
provided on July 31, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPECT scan. 
 
You asked the Plan to pre-approve a SPECT scan. You say that the patient had cerebrovascular accident in 
June 2021, and ultimately was found to have a complete right carotid artery occlusion. Other diagnoses include 
type 2 diabetes mellitus. The Plan denied your request. The Plan says under Medicare guidelines, your request 
is not medically necessary because the records show that the enrollee does not have any evidence of ischemic 
heart disease or dilated cardiomyopathy. 
 The Plan follows Medicare rules.  
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is not medically necessary. Our physician reviewer found the enrollee is a male with medical 
history of cerebrovascular accident (CVA) and Diabetes Mellitus Type II. The echocardiogram was normal. 
Noted in the documentation is the patient having good exercise tolerance without active cardiac symptoms. A 
nuclear stress testing (SPECT) was requested. However, the provided records did not clearly show a 
contraindication to exercise stress testing for this enrollee, and there was no report of active cardiac symptoms 
such as angina to justify testing altogether.  
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging, tomographic (SPECT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you had the ultrasound because you 
are a breast survivor. You say that you can only have ultrasounds and they have been covered before. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 a specialty physician for other Medicare-covered outpatient diagnostic tests. Covered services 
include but are not limited to: Other outpatient diagnostic tests such as: Electromyogram (EMG), 
Cardiovascular Stress Tests (See Advanced Radiology for Nuclear Stress Tests), Echocardiograms, and EKG. 
 You have been asked to pay a $40 copayment for an ultrasound. The 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 waive 
the copayment for an ultrasound provided on January 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for topical aminolevulinic acid hcl provided 
on September 24, 2021. 
 
You asked the Plan to waive the coinsurance for topical aminolevulinic acid. You say that you should not be 
responsible for the $76.43 since the treatment did not work for you. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $76.43, which is less than 20% coinsurance for topical aminolevulinic acid. 
Topical aminolevulinic acid falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for topical aminolevulinic acid hcl provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the requested provider you have been 
seeing since last year and you would like to continue to see the OON provider. The Plan denied your request. 
The Plan says they spoke to the OON provider, and they confirmed the enrollee is not in active treatment with 
them and they can safely transfer to an in-network provider. Also, the enrollee already has an approved 
authorization with 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for this provider or the referring 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 drug testing provided on October 27, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you were seeing this provider prior to 
them becoming an OON provider and you would like to see them again. The Plan denied your request. The 
Plan says they confirmed with the OON provider that the enrollee is not in active treatment with them, and they 
can safely transition to an in-network provider. Also, there is already an approved authorization to see an in-
network specialist. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are terrified of falling again. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on January 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that the facility requested the 
physician to provide services to the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chronic care management services provided on 
January 31, 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 assisted living facility (ALF) visit provided on November 
26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ALF visit. You say that the services were medically necessary, and it is 
the facility's responsibility to obtain authorization. The Plan denied your request. The Plan says the services 
were provided OON without obtaining authorization. No payment can be made. 
 
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 assisted living facility (ALF) visit provided on 
November 26, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory pathology testing provided on December 7, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory pathology testing. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory pathology testing provided on 
December 7, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
performed on March 4, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not aware of the 
copayment since the provider informed you it was a screening. 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 outpatient surgery or services.  
 
The record shows there were polyps removed during the procedure. This tissue removal makes the procedure 
diagnostic in nature. Therefore, you have been asked to pay a $100 copayment for the colonoscopy.  The colonoscopy 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 waive the copayment 
for a colonoscopy with polyp removal performed on March 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT provided on December 30, 2021. 
 
You asked the Plan to waive the copayment for a CT. You say that you were in crisis, and you needed the scan. 
The bills from this injury are a burden to you. You are on a fixed income and disagree with the cost share 
applied. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $175 
copayment for each Medicare-covered diagnostic imaging (CT scan, MRI/MRA, myocardial nuclear perfusion 
imaging and PET scans) at an in-network outpatient facility.  
 
 
 
 
 You have been asked to pay $137.10 which is less than the standard $175 copayment. The CT 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 CT provided on December 30, 2021.