Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of bioengineered skin substitute to lower 
extremity chronic non-healing wound. 
 
You asked the Plan to pre-approve application of bioengineered skin substitute to lower extremity chronic non-
healing wound. You say that it is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements for approval. 
 
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 application of bioengineered skin 
substitute to lower extremity chronic non-healing wound. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found a 
bioengineered skin substitute appears to be excessive at this point. There is no medical documentation to support other treatments including offloading of the area, antibiotics, if necessary, Santyl, hydrogels, Aquacel 
AG type dressings, or consistent wound debridement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of application of bioengineered skin substitute to lower extremity chronic non-
healing wound have not been met. Therefore, we decided that the Plan does not have to pre-approve application 
of bioengineered skin substitute to lower extremity chronic non-healing wound.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 01, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel like the Plan should have 
paid more towards the cost of the procedure. 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 $110 
copayment for outpatient radiological diagnostic services, including an ultrasound.. 
 
You have been asked to pay a $110 copayment for the ultrasound. This item/service falls within the outpatient radiological diagnostic services, including an ultrasound. 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 ultrasound provided on September 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoe inserts provided on April 17, 2023. 
 
You asked the Plan to pay for shoe inserts. You say that this was approved and should be covered, please 
reprocess. 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 shoe inserts provided on 
April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from April 26, 2023, to May 18, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not covered. The Plan must 
follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not covered 
by Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with 
pump (E0218) provided from April 26, 2023, to May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and the patient has a 
referral. 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). However, the provider who wrote the referral is not a primary care provider, and they 
are also out-of-network. Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive evaluation (D0150). 
 
You asked the Plan to pay for the dental services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 22, 2023. 
Therefore, we decided that the Plan does not have to pay for the comprehensive evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care supplies provided on August 
04, 2023. 
 
You asked the Plan to waive the copayment for wound care supplies. You say that you are requesting 
reconsideration for the denied claim. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for wound care supplies. This item/service 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 wound care supplies provided on August 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy (29827, 29828, 29823) provided on 
September 20, 2023. 
 
You asked the Plan to pay for the arthroscopy (29827, 29828, 29823). You say that these services were 
medically necessary. 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 the arthroscopy (29827, 
29828, 29823) provided on September 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377), harness for upgrade to 
expandable controller (E2313), and electronic connection between wheelchair controller and two or more 
power seating system motors (E2311). 
 
You asked the Plan to pre-approve expandable controller, harness, and electronic connection. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 expandable controller, harness, and 
electronic connection. 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 adequate strength to 
manage standard power drives. Criteria are not met for K0108, positioning wedge, and K0108, UniLink 
pelvic/thigh additional link. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or 
more power seating system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
October 19, 2022, to November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for D4341 for the upper left and lower left quadrant was exhausted on date of service June 
11, 2022, and D4341 for the upper right and lower right quadrant was exhausted on June 16, 2022. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
October 19, 2022, to November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87481 and 87798) 
rendered on October 12, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says charges considered to be experimental and investigational are excluded from coverage 
under this plan. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is well established in the medical documentation that this enrollee is suffering with thick painful 
toenails that demonstrate subungual detritus. A skin specimen was taken and sent for polymerase chain reaction 
(PCR) testing to evaluate for pathogens. The longstanding standard of care for the evaluation of fungus in skin 
and toenails is the performance of both KOH and fungal culture on the specimen. These laboratory tests are 
inexpensive, sensitive, and specific. It is unclear as to why this patients specimen required PCR testing as 
compared to KOH and fungal culture. 
 
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 pay for laboratory services (procedure code 87481 and 87798) rendered on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three semi-precision abutments (D6192) provided on 
February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 14, 2023. 
Therefore, we decided that the Plan does not have to pay for three semi-precision abutments (D6192) provided 
on February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection provided 
on May 05, 2023. 
 
You asked the Plan to waive the coinsurance for an onabotulinumtoxina injection. You say that you disagree 
with the coinsurance. 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 10% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 10% coinsurance for an onabotulinumtoxina injection. This item/service 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. The total amount you owe is $124.15 ($1,426.50 allowed amount x 10% = 
$124.15). Therefore, we decided that the Plan does not have to waive the coinsurance for an 
onabotulinumtoxina injection provided on May 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory services 
provided on September 27, 2023.
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 you are not able to care for yourself and need IRF 
services to regain your prior level of functioning. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
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 laboratory services provided on July 15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory services 
provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records.  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 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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous ESI. 
While the initial pain relief was 65% for the last epidural steroid injection. It is unclear how many weeks of 
pain relief above 50% were achieved.  
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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 15, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this claim is not a duplicate. Rather, the 
enrollee was transported twice on this date of service. The Plan denied your request. The Plan says these 
ambulance services are not separately payable because they occurred during the enrollee's inpatient hospital 
stay. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport from one hospital to another 
to receive specialized care that is not available at the facility there the patient is an inpatient is not separately 
payable.  Payment for these ambulance services is included in the PPS rate for the hospital. 
 
In this case, the enrollee was in a covered inpatient rehabilitation hospital stay from April 14, 2023, to May 4, 
2023. The enrollee was transported to and from another hospital on April 15, 2023, for assessment of 
weakness. Because this transport occurred during the course of an inpatient hospitalization, payment for this transport is considered part of the PPS payment, and no separate payment is allowed. 
 
We looked at the file and Medicare rules. 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 provided on April 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single-photon emission computed tomography (SPECT) 
myocardial perfusion imaging (MPI).  

You asked the Plan to pre-approve SPECT MPI. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that stress testing with cardiac imaging may be covered 
for certain indications. 
 
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 SPECT MPI. Our reviewer says that the 
enrollee does not meet criteria for this scan. Our physician reviewer found The patient has no cardiac signs or 
symptoms. There is no documentation that the ECG shows an uninterpretable pattern. There is no evidence 
provided that would support the need for radionuclide stress testing at this time. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
patient's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT MPI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single-photon emission computed tomography (SPECT) myocardial perfusion imaging 
(MPI).