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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed represented by code E0261. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that because of the enrollee's medical 
conditions, she will greatly benefit from a hospital bed. The Plan denied your request. The Plan says the notes 
provided do not support the need for a semi-electric hospital bed. The Plan says that the records do not show 
that the enrollee needs the head of the bed to be moved up more than 30 degrees due to a heart or lung disease 
or that she needs position changes. The Plan says that there are no decubitus ulcers. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or  
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 semi-electric hospital bed. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation that the enrollee's condition requires position of the body in ways not feasible in an ordinary 
bed. There is no documentation that the enrollee requires frequent changes in body position or immediate 
changes in body position. There is no documentation that the enrollee's condition requires special attachments 
that cannot be fixed and used on an ordinary bed. There is no documentation that the semi-electric hospital bed 
meets Medicare criteria for medically necessary for this enrollee.  
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed represented by code E0261.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on October 26, 
2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that this is not a new patient visit so 
the copayment should be waived. The Plan denied your request. The Plan says the copayment amount 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 $35 
copayment for each visit to your specialist.  
 
You have been asked to pay a $35 copayment for the specialist visit. Specialist 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 the specialist visit provided on October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary and supported by the 
records provided. The Plan denied your request. The Plan says the enrollee can receive the care needed at a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for hip and knee pain after a fall and was discharged home on March 23, 2022. There is 
ongoing weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) 
provider on March 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on March 26, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like for the claim to be paid. The 
Plan denied your request. The Plan says the rendering and referring providers are both out-of-network 
providers and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 11, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care provided from 
October 29, 2020, to November 5, 2020. 
 
You asked the Plan to waive the copayment for inpatient mental health care. You say that you were admitted 
against your will. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copay, per day, for Medicare-covered hospital stays.  
 
 
  
You have been asked to pay a copay of $225 per day, for days one through seven, for inpatient mental health 
care. Your stay in the hospital was seven days, making the total copay $1575. Inpatient mental health care falls 
within the "Inpatient mental health 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 inpatient mental health care provided from October 29, 2020, to November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for specialist office visits and 
Medicare Part B drugs provided on January 8, 2021 to April 2, 2021.  
You asked the Plan to waive the copayment and coinsurance for specialist office visits and Medicare Part B 
drugs. You say that the charges should be waived. The Plan denied your request. The Plan says the total 
amount 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 physician specialist services, and 20% coinsurance for Medicare Part B drugs.  
 
Please see chart below for a detailed list of all services rendered from dates of service January 8, 2021 to April 
2, 2021. 
 
Date of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
January 8, 2021 
Specialist office visit 
(99213) 
$89 $40 copayment $40 
January 8, 2021 Part B drug (J3490) $36 20% coinsurance $7.20 
January 8, 2021 Part B drug (J2323) $6,717 20% coinsurance $1,343.40 
February 5, 2021 
Specialist office visit 
(99213) 
$89 $40 copayment $40 
February 5, 2021 Part B drug (J3490) $36 20% coinsurance $7.20 
February 5, 2021 Part B drug (J2323) $6,717 20% coinsurance $1,343.40 
March 5, 2021 
Specialist office visit 
(99213) 
$126.50 $40 copayment $40 
March 5, 2021 Part B drug (J3490) $36 20% coinsurance $7.20 
March 5, 2021 Part B drug (J2323) $6,717 20% coinsurance $1,343.40 
April 2, 2021 Part B drug (J3490) $18 20% coinsurance $3.60 
April 2, 2021 Part B drug (J2323) $6,687 20% coinsurance $172.74 
   Total $4,348.14 
 
You have been asked to pay a total of $4,348.14 for specialist office visits and Medicare Part B drugs. Please 
note the services rendered on April 2, 2021 met your maximum out-of-pocket for in-network services for the 
calendar year of 2021 ($5,900), so you were only charged to that maximum.  
 
Specialist office visits fall within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. Medicare Part B drugs fall 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 copayment and coinsurance for specialist office visits and Medicare Part B 
drugs provided on January 8, 2021 to April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing provided on July 16, 2021. 
 
You asked the Plan to pay for the CxBladder Detect. You say that this testing is clinically proven and should be 
covered. The Plan denied your request. The Plan says this is not a covered test as there is not sufficient 
evidence to support it. 
 
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 pay for the CxBladder Detect. Our reviewer says 
that the requested testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found CxBladder is considered experimental/investigational as a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade 
tumors.   
 
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 CxBladder Detect have not been met. Therefore, we decided that the Plan 
does not have to pay for the CxBladder Detect testing provided on July 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided on October 
22, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
they were medically necessary. The Plan denied your request. The Plan says the cost-sharing 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 
$102.73 for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $102.73 for an ultrasound, which is less than the standard $110. Ultrasounds fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an ultrasound (76705) provided on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve the ultra lightweight manual wheelchair. You say that the wheelchair is 
medically necessary. The Plan denied your request. The Plan says the type of chair requested exceeds the 
enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that for this type of chair to be covered the beneficiary 
must require individualized fitting and adjustments for one or more features such as, but not limited to, axle 
configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through 
K0004 manual wheelchair. 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 ultra lightweight manual 
wheelchair. Our reviewer says that the requested wheelchair is not medically necessary. Our physician 
reviewer found the records provided do not clearly document that the requested ultralightweight manual 
wheelchair does not exceed the enrollee's needs and that a standard lightweight manual wheelchair has been 
trialed and failed to meet the enrollee's needs. 
 
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 ultra lightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair (K0005).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), and a guided tissue 
regeneration (D4267) provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft and a guided tissue regeneration. You say that this 
is medically necessary. The Plan denied your request. The Plan says the requested dental services are not a 
covered dental service. 
 
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 pre-approve a 
bone replacement graft (D4263), and a guided tissue regeneration (D4267) provided by a participating 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81408, 81479) rendered by the out-
of-network (OON) provider on February 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81408, 81479) rendered by the out-of-network (OON) 
provider on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician office visits (99214) provided on June 28 to July 
27, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for physician office visits. You say that the services at issue were a necessity for 
your care. The Plan denied your request. The Plan says rules for payment for out-of-network care have not 
been met. 
 
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 physician office visits (99214) provided on June 28 to July 27, 2021, by an 
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037M) rendered by 
the out-of-network (OON) provider on August 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal.  The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence 
analysis (0037M) rendered by the out-of-network (OON) provider on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B injection (J7326) 
provided on March 23, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B injection. You say that you were not told 
about the injection, you cannot afford it, and that the injection did not help. The Plan denied your request. The 
Plan says the coinsurance amount 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 20% 
coinsurance for Medicare-covered Part B prescription drugs.  
 
  
You have been asked to pay $107.47, which is 20% of the Plans allowed amount ($537.37), for the Medicare 
Part B injection. Medicare Part B injections fall 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 the Medicare Part B injection (J7326) 
provided on March 23, 2021.