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

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is needed to confirm a diagnosis of Parkinson's or tremors. 
 
The Plan must follow Medicare rules. Medicare rules say that SPECT scans are covered only when they are 
medically necessary.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the requested 
procedure is primarily used to differentiate between Parkinson's Disease and essential tremor in patients who 
have features of both conditions. It has not however been shown to be of diagnostic utility in the evaluation of 
other conditions/disorders (aside from epilepsy) in the clinical setting. The diagnostic utility of this procedure 
therefore is unable to be fully determined at this time. It is otherwise not clear that performance of the 
requested testing is consistent with current standards of care or practice. Nor can it be said that this is the most 
appropriate service which can be provided to the enrollee at this time. As such the request would not meet the 
Medicare definition of medical necessity. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a single photon emission computed tomography (SPECT) scan for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service February 
9, 2022. 
 You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into 
payment for code 93976. 
 
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 
76705-26 is a column II code to column I code 93976. 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 76705-26 billed for date of service 
February 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 13, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should only have one ER 
copayment for both visits. 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 emergency care visit.  
 
The record shows that you were seen and discharged from the ER on January 12, 2022. You were then seen 
again on January 13, 2022, for a different diagnosis. Therefore, you have been asked to pay a $120 copayment 
for the ER visit. The ER visit falls within the Emergency Care 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 emergency room (ER) visit provided on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72148) 
 
You asked the Plan to pre-approve the magnetic resonance imaging. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has posterior right hip pain. The record does not indicate the occurrence of acute injury. The 
record does not demonstrate the existence of red flag symptoms or physical examination findings. The record 
does not document the trial of conservative measures including physical therapy for the noted diagnosis. 
 
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 magnetic resonance imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
device provided from December 12, 2021, to February 12, 2022. 
 
You asked the Plan to waive the coinsurance for the AED device. You say that you should not have to pay 
monthly for rental equipment. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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), such as AED devices. 
 
 Item Allowed Amount 20% Coinsurance 
AED  December 12, 2021 $3,168.69 $633.73 
AED  January 12, 2022 $3,247.91 $649.58 
AED  February 12, 2022 $3,247.91 $649.58 
Total:  $1,932.89 
 
You have been asked to pay $1,932.89, which is 20% of the allowed amount for the AED device. The AED 
device 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 an automatic external defibrillator (AED) device provided from 
December 12, 2021, to February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care telehealth visit provided on 
February 18, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you were not seen that day and 
had no tests done. 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 $5 
copayment for each telehealth primary care visit.  
 
The record shows that you had a telehealth visit on February 18, 2022. Therefore, you have been asked to pay a 
$5 copayment for the telehealth visit. The telehealth visit falls within the Telehealth 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 a primary care telehealth visit provided on February 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
and left hip. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no mention of an MRI being needed from the doctor on 4/19/22. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found you were evaluated 
most recently on 4/19/22. The neurological exam was normal, and no red flags were seen. There is no mention 
in the notes of considered requesting MRI of either the cervical spine, or the left hip. Without a valid order, 
both tests are denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine and left hip.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abiraterone.
You asked the Plan to pre-approve Abiraterone. The Plan denied your request. The Plan says this drug is not covered under your Part B plan.
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 Abiraterone.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
September 17, 2021, through September 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient care is not considered reasonable or necessary for this member and could have been managed at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 17, 2021, through 
September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided from March 25, 2022, to 
March 26, 2022. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you were admitted to the hospital and the 
doctor that discharged you was out-of-network, and you had no control over this. You also say that you were 
sent to the nearest hospital from an urgent care facility because they did not have imaging equipment. The Plan 
denied your request. The Plan says no clinical notes or documentation for the hospital visit were submitted. The 
Plan also says that the request does not show that you had abnormal vital signs, severe pain, or that you had a 
urinary tract infection or a stone removal procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital stay provided 
from March 25, 2022, to March 26, 2022. have been met. Medical records for this case were not submitted to 
show that the inpatient stay was medically necessary. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital stay provided from March 25, 2022, to March 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary and the only way to 
improve. The Plan denied your request. The Plan says this cannot be approved. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you got pain relief from herbal treatment. There is no documented trial of bracing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 19, 2022.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the eyewear benefit has been exceeded.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear allowance benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided by on January 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for group psychotherapy on January 13, 2022, 
to January 24, 2022. 
 
You asked the Plan to waive the copayments for group psychotherapy. You say that have been going to this 
facility since November of 2021 and was never charged a copayment. The Plan denied your request. The Plan 
says the cost-sharing amount you are being charged 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 a $40 
copayment for each Medicare-covered group session for outpatient mental health services provided by a mental 
health professional other than a psychiatrist. There were 2 visits, resulting in a total copayment amount of $80.  
 
 
 
 You have been asked to pay a $40 copayment for group psychotherapy. Group psychotherapy falls within the 
outpatient Medicare-covered group session. You have a $40 copayment for each outpatient mental health group 
session. The allowed amount on this claim is $80. 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 
group psychotherapy on January 13, 2022, to January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid check (92593) provided on March 10, 2022. 
 
You asked the Plan to pay for a hearing aid check. You say that the services at issue were a necessity for your 
care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 92593 has a Status Indicator of N on the Physician Fee Schedule. This means that CPT 
code 92593 represents a non-covered service. Based on this information, we decided that Medicare rules for 
coverage of a hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid check (92593) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for health fitness membership provided on  
January 1, 2020. 
 
You asked the Plan to reimburse you for health fitness membership. The Plan denied your request. The Plan 
says based on the information received, you submitted your 2020 wellness reimbursement past the deadline of 
March 31, 2021. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file and the Plans rules. The file shows that you submitted your 2020 wellness 
reimbursement past the deadline of March 31, 2021. Therefore, we decided that the Plan does not have to 
reimburse you for health fitness membership provided on January 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Physical Therapy from February 24, 2021 
through June 24, 2021. 
 
You asked the Plan to waive the copayments for Physical Therapy. You say that you were unaware there was a 
copayment for this. The Plan denied your request. The Plan says the cost share 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 a $40 
copayment for each covered physical, occupational and speech therapy visit. for Physical Therapy. There were 
14 visits between February 24, 2021 and June 24, 2021, therefor the total cost share is $560. 
 
You have been asked to pay a $40 copayment for each covered physical, occupational and speech therapy visit. 
for Physical Therapy. Physical Therapy falls within the Outpatient Rehabilitation 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 copayments for Physical Therapy from February 24, 2021 through June 24, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair (K0861) and 
related accessories and features. 
 
You asked the Plan to pre-approve a power wheelchair and related accessories. You say that the requested item 
is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair 
received by you in July 2018. Therefore, the requested replacement is for an item that has not outlasted its 
reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a power 
wheelchair and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement Group 3 power wheelchair (K0861) and related accessories and features.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2021 to November 
20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on September 20, 2021 to 
November 20, 2021 by an out-of-network (OON) provider.