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

 
We decided that the Plan does not have to pre-approve a prosthetic leg and an additional knee flexion feature. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for K3 knee and foot, as well as K4 high activity control frame, does not meet 
Medicare criteria as reasonable and 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have a medical history including diabetes mellitus and a traumatic above knee amputation in the 
distant past who is asking for a replacement prosthesis. The documentation doesn't indicate that you are an 
advanced ambulator. The documentation indicates that you require an assistive device for mobility. The 
documentation does not support that you are a K3 or K4 ambulator.  
 
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 a prosthetic leg and an additional knee flexion feature.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve robotic sacrocolpopexy surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you have been under this doctors care 
for about 3 months now and you want him to perform the surgery and direct after care in a hospital setting. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 
robotic sacrocolpopexy surgery 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 the definitive drug testing provided on August 25, 2021. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the drug testing 
was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 51-year-old male who has chronic pain and is being prescribed ongoing opiates for 
pain control. The provided documentation describes the enrollee as having regular urine drug screenings which were recently predictable and appropriate, showing positive for opiates as prescribed. There was no recent 
urine drug screening prior to the definitive testing being performed that would suggest an abnormality, and no 
notes describe signs of abuse/misuse to justify followup testing, particularly for so many drug classes that do 
not apply to the enrollee's clinical situation. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on January 4, 2022. 
 
You asked the Plan to pay for ambulance response without transport. You say that the issue was resolved by 
the ambulance crew before you needed to be transported, therefore transport was not necessary. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport (A0998) provided on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 73630 (1 unit) remains not supported. 
 
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 asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the podiatry note says that "x-rays 
were obtained" implying both feet were image. However, this is not substantiated in the records submitted. 
There is no description of the technique or number of views. There is no report. Absent such documentation 
there is insufficient support for payment of the disputed charge. 
 
 
 We looked at this coder'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 pay for imaging services provided to the enrollee on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 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 August 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you are at a high fall risk and need 
ongoing therapy. The Plan denied your request. The Plan says you have been receiving therapy for the last 
three months and your progress has plateaued. There is no documentation that shows you have skilled needs 
that require the professional skills of a therapist. Your therapy can safely proceed through a home exercise 
program, self-management program, or caregiver assisted program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy, and the documentation does not reveal that you require the unique skills of a professional 
therapist to safely and effectively provide treatment or that the services can only be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home 
exercise program. The requested services are not part of a maintenance program, and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further deterioration. Ongoing skilled therapy is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 16 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) with accessories (A9999) and sales tax 
(S9999) purchased on May 12, 2021. 
 
You asked the Plan to pay for a wig with accessories and sales tax. You say that this should be covered. The 
Plan denied your request. The Plan says this is excluded from coverage. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) with 
accessories (A9999) and sales tax (S9999) purchased on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve osteogenesis stimulator. You say that you are requesting the approval of the 
bone stimulator, code E0747, because the enrollee meets the insurance criteria. The Plan denied your request. 
The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve osteogenesis stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee fell from a 25-foot height and 
suffered bilateral calcaneal fractures in February 2022. Following decompression, the requested service was 
ordered. The record provided does not include x-rays obtained 90 days apart. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pay for the services. You say that you know the correct diagnosis you should have used. 
The Plan denied your request. The Plan says a corrected claim was not received with the appeal. 
 
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 anesthesia services provided to the 
enrollee on November 2, 2021 have been met. The case file indicates that you understand that you billed the 
claim wrong. However, you have not submitted a corrected claim yet at this time. Z79.81 is not a valid 
diagnosis code in this case.. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided to the enrollee on November 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on November 21, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance transport and ground mileage. The Plan denied 
your request. The Plan says the Plan says that the enrollee's claim history shows the enrollee was inpatient at 
the time these services were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is included in the payment to the facility.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transport and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for a foot x-ray, ultrasound of the leg arteries, 
and a podiatry office visit provided on December 8, 2021. 
 
You asked the Plan to reduce the copayments for an x-ray, an ultrasound, and a podiatry office visit. You say 
that the doctor used a handheld doppler on both of your feet, which only took two minutes. You also say that 
you did not have an ultrasound by a sonographer, other than an x-ray. 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 $15 
copayment for an in-network x-ray. The Plan contract also says that enrollees must pay a $110 copayment for 
in-network radiological diagnostic service, including ultrasounds.  The Plan contract also says that enrollees 
must pay a $40 copayment for an in-network podiatry office visit. 
 
The record shows a doppler is considered an ultrasound. The record also shows this claim was approved, and 
you have a cost sharing amount. You have been asked to pay a $15 copayment for an x-ray. You have also 
been asked to pay a $110 copayment for an ultrasound. An x-ray and ultrasound fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a 
$40 copayment for a podiatry office visit. A podiatry office visit falls within the Podiatry Services benefit 
category. You have been asked to pay a total of $165 ($15 copayment + $110 copayment + $40 copayment = 
$165). 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 reduce the copayments for a foot x-ray, ultrasound of the leg arteries, 
and a podiatry office visit provided on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine surgery with placement of Coflex device. 
 
You asked the Plan to pre-approve lumbar spine surgery with placement of Coflex device. You say that the 
lumbar spine surgery with placement of Coflex device is medically necessary. The Plan denied your request. 
The Plan says the lumbar spine surgery with placement of Coflex device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar spine surgery with placement of 
Coflex device. Our reviewer says that the lumbar spine surgery with placement of Coflex device is not 
medically necessary. Our physician reviewer found the Coflex device is considered experimental. High failures 
have been reported with similar devices. The requested Coflex device is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spine surgery with placement of Coflex device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar spine surgery with placement of 
Coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit and botox injection 
provided on March 3, 2021. 
 
You asked the Plan to waive the deductible for the specialist visit and botox injection. You say that the 
procedure was always paid by insurance. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the specialist visit and botox injection were 
received on March 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a 
specialist office visit and botox injection provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on December 
16, 2021. 
 
You asked the Plan to waive the copayment for the stress test. You say that you were not aware of the high 
copayment. 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 $325 
copayment for diagnostic radiology services that are not ultrasounds.  
 
 
 You have been asked to pay a $325 copayment for the stress test. The stress test 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 nuclear stress test provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology specialist telehealth visit 
provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you thought telehealth 
was covered at 100%. 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 $45 
copayment for an in-network specialist telehealth visit.  
 
You have been asked to pay a $45 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
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 cardiology specialist telehealth visit provided on January 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
26, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not pay this 
ambulance bill. 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 $330 
copayment for in-network ambulance services.  
 
You have been asked to pay a $330 copayment for ambulance services ($229.19 + $100.81 = $330). 
Ambulance services 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 services provided on October 26, 2021.