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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 10, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the Plan did 
not pay any benefit for the service performed by an in-network provider with prior authorization. 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 $310 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $310 copayment for a magnetic resonance image (MRI). 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 $188.72, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on February 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Ozempic. Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on November 25, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were not 
aware of the copayment for the MRI and no one requested a payment at the time service was rendered. 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 $150 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $150 copayment for a magnetic resonance image (MRI). 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
magnetic resonance image (MRI) provided on November 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of viewless than one whole jaw (D0364) and the consultation-diagnostic 
service provided by a dentist or physician other than requesting dentist or physician (D9310) on January 31, 
2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation with limited field of viewless than one whole jaw 
(D0364) and the consultation-diagnostic service provided by a dentist or physician other than requesting dentist 
or physician (D9310) on January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no sacroiliac joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on March 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided on March 9, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting reconsideration for the 
denial of occupational therapy. The Plan denied your request. The Plan says you do not meet the guidelines for 
occupational therapy services.  
 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 the therapy services. 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 there are no goals of care identified indicating a need for skilled 
therapy and no functional deficits. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 36 occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LASIK surgery.  
You asked the Plan to pre-approve the Lasik surgery. You say that you have had double vision for six years 
after cataract surgery. You say Lasik surgery is the only way to solve this problem. The Plan denied your 
request. The Plan says the service is specifically excluded from coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, LASIK surgery is not covered by Medicare or through 
your supplemental benefits.  Based on this information, we decided that the Plan's rules for coverage of the 
Lasik surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the LASIK 
surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5213). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollees benefit for the requested dental item 
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 the enrollees benefit for the requested dental item was exhausted on date of service March 18, 2022. 
Specifically, the Plans contract states that one lower partial denture is covered every 60 months.  
  
 
 
The enrollee previously received this dental item on March 18, 2022, less than 60 months prior, which was paid 
for by the Plan. Therefore, the enrollees benefit for the requested dental item in this case has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 September 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the contact lenses.  
You asked the Plan to pre-approve the contact lenses. You say that you require hybrid contact that are specially 
made to help the cornea come into position to improve your vision. The Plan denied your request. The Plan 
says the cost of the contact lenses exceeds the maximum allowable benefit of $200. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the contact lenses up to a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan benefit limit for contact lenses is $200 once 
every two years. Based on this information, we decided that the Plan's rules for coverage of the contact lenses 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the contact lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (Vest 
Airway Clearance System). 
 
You asked the Plan to pre-approve the Vest Airway Clearance System. You say that this enrollee has a 
complicated respiratory status and has failed standard treatments.  The Plan denied your request. The Plan says 
although the enrollee does have chronic obstructive pulmonary disease (COPD), there is no documented 
diagnosis of bronchiectasis or cystic fibrosis and there is no evidence of pathology consistent with 
bronchiectasis or cystic fibrosis on recent CT of the chest. There is no history of neuromuscular disorder. While 
the enrollee may benefit from the requested chest wall oscillation device, the Medicare coverage criteria are not 
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 Vest Airway Clearance System. Our 
reviewer says that the requested Vest Airway Clearance System is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has severe COPD with a chronic cough and 
sputum production.  There is no diagnosis of bronchiectasis, cystic fibrosis, or neuromuscular disease.  There is 
inadequate evidence that this device is beneficial in the treatment of COPD, and Medicare does not cover it for 
that diagnosis. 
 
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 Vest Airway Clearance System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a high frequency chest wall oscillation system (Vest Airway 
Clearance System).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device.  
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the records provided support the need 
for the requested device. The Plan denied your request. The Plan says the requested 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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on April 03, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the amount 
billed and the copayment applied is too high for this procedure and is beyond your financial means. 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 magnetic resonance image (MRI). 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 $236.22, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on April 03, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99232, 
99232 and 99232. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 93351.  
 
You asked the Plan to pay for radiological services provided on November 30, 2022, billed with code 93351.. 
You say that the claim was billed correctly and should be paid. The Plan says that the billed procedure requires 
modifier 26. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99232, 
99232 and 99232.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99232, 99232 
and 99232.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93351. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. The TC of 
radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient 
Prospective Payment System (OPPS) to the hospital. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 93351 have not been met. In this case, an appropriate 
modifier to indicate the professional component has not been billed with procedure code 93351. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 93351. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is covered when specific 
criteria are met. 
 
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 power scooter. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the scooter is authorized when 
necessary to complete MADLs in the home. The scooter is not medically necessary for the enrollee to complete 
MADLs in the home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient laboratory services provided on January 24, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON outpatient laboratory services. You say that the approval for Procrit 
should have allowed for coverage of the laboratory services in dispute.  The Plan denied your request. The Plan 
says prior authorization for these services was not obtained.  
 
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 
OON laboratory services at issue. We found no exception that would require the Plan to pay for these services 
from an OON provider. Therefore, we decided that the Plan does not have to pay for outpatient laboratory 
services provided on January 24, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chemotherapy injection provided on 
January 13, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy injection. You say that you already met your 
maximum out-of-pocket for 2023. 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% 
coinsurance for Medicare Part B-covered chemotherapy drugs.  
 
You have been asked to pay $3,360 coinsurance for chemotherapy injection. The maximum out-of-pocket was 
met with the processing of this claim; Thus, the amount owed is less than the standard coinsurance for 
Medicare Part B drugs. 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a chemotherapy injection provided on January 13, 2023.