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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with power tilt and 
recline, power elevating leg rests and a skin protection cushion. 
 
You asked the Plan to pre-approve the Group 3 PWC with requested additional components. You say that you 
argue that the enrollee's statements regarding the use of a PWC in the home were not correctly documented. 
You argue that the enrollee was not being truthful when she stated that the PWC would only be used outside 
the home due to her mental condition and mood instability. You state that you should not be required to handle a manual wheelchair when you struggle to do so when a PWC would be much better for both you and the 
enrollee. You indicate that this denial is based on invalid information and should be reconsidered. The Plan 
denied your request. The Plan says the records do not clearly show that the use of a PWC is necessary for the 
enrollee to complete MRADLs in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 3 PWC with requested 
additional components. Our reviewer says that the documentation does not support the criteria for the requested 
PWC are met. Our physician reviewer found the documentation doesn't support that the power wheelchair is for 
use inside the home. Additionally, the documentation doesn't support that the member would be able to operate 
a PWC, and there is a caregiver who can operate a manual wheelchair. 
 
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 Group 3 PWC with requested additional components have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with 
power tilt and recline, power elevating leg rests and a skin protection cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 2, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on February 2, 2022, by an out-of-network 
provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS) for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has no clear documentation showing standardized scores. There is no 
documentation of the patients previous pharmacologic treatment or if the patient is undergone 
Electroconvulsive Therapy (ECT) or repetitive Transcranial Magnetic Stimulation (rTMS) in the past. With the 
lack of documentation this patient does not meet the criteria for treatment with repetitive Transcranial Magnetic 
Stimulation (rTMS); therefore, is not reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repetitive transcranial magnetic stimulation (rTMS) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy telehealth services 
provided from February 15, 2022, to March 29, 2022. 
 
You asked the Plan to waive the copayments for the psychotherapy telehealth services. You say that you were 
not aware of the copayment change. 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 $30 
copayment for each telehealth visit.  
 
You have been asked to pay a $30 copayment for each of the 4 visits for the psychotherapy telehealth services, 
for a total of $120. The psychotherapy telehealth services fall within the Outpatient 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 copayments for psychotherapy telehealth services provided 
from February 15, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided April 
19, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the place of service code 31 is appropriate 
and should be paid accordingly. Please reprocess for prompt payment as your provider rendered services in 
good faith and reimbursement should be forthcoming. The Plan denied your request. The Plan says the point of 
service does not match the facility claim 
 
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, the CPT Code Manual definition of code 99310 is subsequent nursing facility care, per day. 
 
 We find that CPT code 99310 is not supported in the medical record. Specifically, the claim was billed with 
point of service 31 for inpatient skilled nursing facility. The claims history shows that the correct POS should 
be 32 for long term nursing facility. Based on this information, we decided that Medicare rules for coverage of 
the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent nursing facility care (99310) provided April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit on March 01, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you are at odds with the $35 
copay because you were not told that there would be one. The Plan denied your request. The Plan says the cost-
sharing 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 $35 
copayment for each telehealth specialist visit. Covered services include: Certain telehealth services, including: 
primary care physician (PCP) visits, specialist visits, home health visits, outpatient mental health services, 
outpatient psychiatric services, outpatient substance abuse services, and diabetes self-management training. 
 
You have been asked to pay a $35 copayment for telehealth visit. Telehealth visits fall within the 
Physician/Practitioner services, including doctor's 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 telehealth visit on March 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on September 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you are the only provider that has a contract 
with the facility and there was no time to obtain an authorization. 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. 
 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 radiology services provided on September 9, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 1, 2021, to April 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.   
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided from April 1, 2021, to April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower (99999, S5165). 
 
You asked the Plan to pre-approve a walk-in shower. You say that it is too difficult and unsafe to step over the 
tub to take a shower. The Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower (99999, S5165).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on January 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care, per day (99305) provided 
January 5, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the physician providers are employees of 
the facility and the physician portion of the bill should be submitted with any paid for services rendered under 
the facilities TIN# and NPI. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for initial nursing facility care, per day (99305) provided January 
5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance treatment in place provided on 
March 26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance treatment. You say that you were treated for 15 
minutes and were not taken to the hospital by the ambulance. 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 $240 
copayment for each ambulance service, including evaluation, treatment, or transportation.  
 
You have been asked to pay a $240 copayment for the ambulance treatment. The ambulance treatment falls 
within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance treatment in place provided on March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth specialist visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for telehealth specialist visit. You say that the telehealth visit 
shouldn't be as much as an in person visit so you shouldn't be charged this much. 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 $30 
copayment for each in network specialist telemedicine visit. 
 
You have been asked to pay $30 copayment for telehealth specialist visit. Telehealth 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 telehealth specialist visit provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prolia injection provided on April 21, 
2022. 
 
You asked the Plan to waive the coinsurance for the prolia injection. You say that you have a low-income 
subsidy and never had to pay coinsurance before. The Plan denied your request. The Plan says the coinsurance 
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 10% of 
the cost for Part B covered drugs administered at non-hospital-affiliated facilities.  
 
You have been asked to pay $144.56 for the prolia injection (allowed amount =$1,445.61 x 10%). The prolia 
injection 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 the prolia injection provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 22, 2021. 
 
You asked the Plan to pay for chiropractic care. The Plan denied your request. The Plan says as a managed care 
Plan, Medicare rules allow us to restrict members to our network and deny out of network care except in rare 
circumstances. 
 
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 
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 chiropractic care provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI) with fluoroscopic guidance. 
 
You asked the Plan to pre-approve the ESI. The Plan denied your request. The Plan says that the incorrect code 
was requested. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs must be performed under CT or fluoroscopy 
image guidance with contrast,10 unless the patient has a documented contrast allergy or pregnancy where 
ultrasound guidance without contrast may be considered. 
 
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 ESI. Our reviewer says that the 
requested ESI is medically reasonable and necessary. Our physician reviewer found that the provider writes 
that the requested procedure is an epidural steroid injection performed with fluoroscopic guidance. 
The Plan has indicated that they will approve the appropriate CPT code (62323). 
 
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 ESI have been met. Please note that this decision is regarding an ESI with 
imaging guidance as this is required by the LCD. As such, the originally requested code is not approved, but 
the injection with the planned imaging is approved if the claim is coded correctly. Therefore, we decided that 
the Plan has to pre-approve an epidural steroid injection (ESI) with fluoroscopic guidance.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that it was the facilities 
protocol to use the ambulance to the hospital and you would like the copayment waived. The Plan denied your 
request. The Plan says the proper copayment was applied for the service rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
  You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transportation provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81161, 81286, 81410, 81411, 81413, 81414, 
81479) provided October 20, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says rules for coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed are not eligible for payment for cardiovascular 
screening. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81161, 81286, 
81410, 81411, 81413, 81414, 81479) provided October 20, 2021.