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

 
We decided that the Plan does not have to pay for procedure code 0117U provided on October 5, 2022. 
 
You asked the Plan to pay for procedure code 0117U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0117U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0117U 
provided on October 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine. 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that you need the CT scan so you 
can have your back surgery. The Plan denied your request. The Plan says a CT scan of the lumbar spine is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the lumbar spine. Our 
reviewer says that a CT scan of the lumbar spine is not medically necessary. Our physician reviewer found that 
you have low back pain and right sciatica. Also, your neuro exam was normal, and no plain x-rays were found 
in the chart. Although there are no red flags and no conservative management in the chart the medical necessity 
of the requested CT scan of the lumbar spine has not been met. 
 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 CT scan of the lumbar spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the lumbar spine.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425) provided on December 24, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 A0425 is not supported in the medical record. Specifically, the claim did not include a 
valid primary diagnosis code. Diagnosis code F05 has a "code first" note and cannot be used as a primary 
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the ambulance 
services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0425) provided on December 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the upper extremity joint. 
 
You asked the Plan to pre-approve an MRI of the upper extremity joint. You say that you have been having 
pain in your left shoulder. The Plan denied your request. The Plan says an MRI of the upper extremity joint is 
not medically necessary.  
 
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 an MRI of the upper extremity joint. 
Our reviewer says that an MRI of the upper extremity joint is not medically necessary.  Our physician reviewer 
found that during an encounter on February 10, 2023, it indicated that you have slight weakness of the left 
upper extremity including a history of strokes. Although the plain x-rays were negative there were no 
conservative therapy such as physical therapy being attempted. Also, there are no provocative maneuvers done 
to pinpoint likely internal derangement of the shoulder. Therefore, without a red flag the medical necessity of 
the MRI of the upper extremity joint has not been established. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the upper extremity joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI of the upper extremity joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on October 24, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the 
copayment applied for a CT scan is excessive and in conflict with Medicare Managed Care regulations. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $275 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The enrollee owes a total of $198.35, which is less than the standard copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral and 
panoramic x-rays (D0150, D0230, D0220, D0330) provided on May 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation, intraoral 
and panoramic x-rays (D0150, D0230, D0220, D0330) provided on May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qulipta. 
 
You asked the Plan to pre-approve Qulipta. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Qulipta.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 13, 2023. 
 You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 the ambulance services provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper 
extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that you need the MRI for pain in your arm. The Plan 
denied your request. The Plan says the criteria for coverage have 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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records do not show a red flag to mandate 
immediate MRI without a 6-week trial of the planned physical therapy. The medical necessity of the requested 
MRI has not been established. 
 
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 an upper extremity joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 19, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you received 
two procedures on the same day at the same location and would like to know why there is no coverage for the 
CT scan. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $170 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $170 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is 111.50, which is less than the standard copayment for CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on December 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that you would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that 
a CT scan of the abdomen and pelvis is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer 
found that you have a history of renal stones and with your fluctuating pain there is a possibility of ureteral 
stones which needs to be assessed. Therefore, a CT scan of the abdomen and pelvis is 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 a CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a CT scan of the abdomen and pelvis.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have 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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found  there is no contraindication to a conservative 
trial of management including physical therapy prior to going forward with a follow-up MRI to the one she had 
a few years ago per the records. Medical necessity of the requested MRI has not been established. 
 
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 lumbar spine.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the cervical spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that 
an MRI of the cervical spine is not medically necessary. 
 
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 an MRI of the cervical spine. Our 
reviewer says that an MRI of the cervical spine is medically necessary. Our physician reviewer found that the 
enrollee is being evaluated for a possible permanent spinal cord stimulator for lumbar spine issues. Also, the 
enrollee has gait instability and other symptoms that could indicate a cervical cord disease. Therefore, the 
requested MRI of the cervical spine is 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 an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan has to pre-approve an MRI of the cervical spine.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
February 03, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you should not have to 
pay for the lab services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for the laboratory services. This item/service falls within the in-
network 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 the laboratory services provided on February 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient thyroid biopsy 
provided on July 07, 2022. 
 
You asked the Plan to waive the copayment for an in-network outpatient thyroid biopsy. You say that you were 
told you did not have a copayment for this procedure. Therefore, you should not have to pay. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for an in-network outpatient thyroid biopsy. This item/service 
falls within the outpatient hospital 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 an in-network outpatient thyroid biopsy provided on July 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray and magnetic resonance 
imaging (MRI) provided on February 22, 2023. 
 
You asked the Plan to waive the copayment for the chest x-ray and MRI. You say that you are financially 
unable to pay the applied copayment. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 
copayment for each x-ray service and $175 copayment for each advanced imaging service (MRI, MRA, CT 
and PET scan). 
 
You have been asked to pay a total of $195 for the chest x-ray and MRI ($20/x-ray + $195 MRI = $195).  
The x-ray and MRI 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 the chest x-ray and magnetic resonance 
imaging (MRI) provided on February 22, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the thorax provided on December 
22, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 pay for the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the revised criteria for lung cancer screening in 
2022 had been revised such that coverage applied for patients with the required smoking history through age 
80.  Thus, the enrollee should be covered for the LDCT performed at age 79. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pay for a 
computed tomography (CT) scan of the thorax provided on December 22, 2022.  
 
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.