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

 
We decided that the Plan does not have to pay for codes U0005 and U0003 for date of service February 11, 
2022. 
 
You asked the Plan to pay for codes U0005 and U0003. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 codes U0005 and U0003 are not payable as billed. Specifically, this service was billed with 
diagnosis code Z36.89, which is for encounter for antenatal screening for mother. This diagnosis code has a 
M" indicator for maternity age 9-64. Antenatal screening of the mother is done to help identify potential 
increased risks to the fetus or mothers health prenatally. Review of the file shows that the enrollee was over 
the age of 64 at the time of service. Based on this information, we decided that Medicare rules for coverage of 
codes U0005 and U0003 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
U0005 and U0003 for date of service February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a T11 and L1 kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasties. You say that the enrollee is in severe pain. The enrollee 
has compression fractures and history of osteoporosis. You say that the enrollee's magnetic resonance imaging (MRI) shows mild compression deformity superior inplateT11 and T12. You say that the enrollee has L1 
lumbar vertebrae with delayed healing from the subsequent encounter. You also say that osteopenia was 
determined by x-ray from September 2022. The Plan denied your request. The Plan says there is no magnetic 
resonance imaging (MRI) documentation of 25% vertebral body height reduction to T11 and L1. 
 
The Plan follows Medicare rules. Medicare rules say that both percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered reasonable and necessary when 
an acute or subacute osteoporotic vertebral compression fracture is present. 
 
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 kyphoplasties. Our reviewer says 
that the requested kyphoplasties are not medically necessary. Our physician reviewer found the provided 
documentation does not clearly indicate that acute or subacute fracture is present. The reviewer also found that 
there is no documentation of a progression of the body height loss, the worsening of pain, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. The reviewer also found 
there is other plausible causes of pain. Therefore, the reviewer found that the requested kyphoplasties are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the kyphoplasties have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a T11 and L1 kyphoplasty.
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 June 19, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were 
advised that the CT scan was covered and there would be no cost share. 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 tests. 
 
You have been asked to pay a $170 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 $112.19, 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 June 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 19, 2023, to May 31, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with the copayments applied to the services provided. 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $100 for PT services ($25 per visit x 4 
visits = $100). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on May 19, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and blood collection provided on April 26, 
2023. 
 
You asked the Plan to pay for an office visit, and blood collection. 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 an office visit, and blood 
collection provided on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided on March 10, 2023. 
 
You asked the Plan to pay for drug testing services. You say that this is medically necessary and we treated the 
patient in good faith. 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 drug testing services 
provided on March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the requested kyphoplasty is medically 
necessary. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when the criteria listed in 
the Medicare rules section 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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the detailed documentation is not 
clear regarding an acute or subacute osteoporotic fracture at L1, as there are no diagnostic imaging studies 
provided. Additionally, there is no documentation of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there are other 
plausible causes of pain. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control identified with code E2331. 
 
You asked the Plan to pre-approve an attendant control. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that a beneficiary-operated joystick has 
been requested and approved by the Plan. This means an attendant control cannot be covered in addition to the 
beneficiary-operated joystick. Based on this information, we decided that Medicare rules for coverage of an 
attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
attendant control identified with code E2331.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick. 
 
You asked the Plan to pre-approve expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick. 
You say that the requested expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick 
are medically necessary. The Plan denied your request. The Plan says the requested expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are 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 expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. Our reviewer says that the requested expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are not medically necessary. Our physician reviewer 
found an expandable controller is an electronic system that can accommodate one or more additional features 
and can operate 3 or more powered seating options. The requested electrical accessories are not medically 
necessary as the member does have use of the upper extremity and can operate and control the power options 
using the switches that are included in the basic wheelchair. There is not a medical need for the upgraded 
electronics. 
 
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 (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
provided on May 26, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan. You say that you thought 
the maximum owed would be a $35 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 a $170 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $170 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 $108.72, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to reduce the copayment for a computed 
tomography (CT) scan provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI testing provided on March 15, 2023. 
 
You asked the Plan to pay for the Guidance UTI testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance UTI testing provided on March 15, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 07, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were advised that the services 
would be covered by the Plan because an authorization was obtained. 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 prescription drugs. 
 
You have been asked to pay 20% coinsurance for an 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 you owe is 904.13, which is 20% of the allowed amount for a Medicare Part B drug 
injection ($4,520.64 allowed x 20% = $904.13). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an injection provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a care plan assessment provided on March 06, 2023. 
 
You asked the Plan to pay for a care plan assessment. 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 a care plan assessment 
provided on March 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on June 14, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that the services should be covered. 
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 principal care 
management services provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is medically necessary and needs to be  covered. 
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 an office visit provided 
on April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on April 15, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that verification of benefits and/or 
authorization of care was obtained from a Plan representative. 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 inpatient hospital 
care provided on April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on April 05, 2023. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this patient is in a facility, and you 
depend upon the facility staff for any verification or prior authorization. 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 a skilled nursing facility 
visit provided on April 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 19, 2023. 
 
You asked the Plan to pay for foot orthotics. You say that you want this item reimbursed as you bought it out of 
pocket. 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 foot orthotics provided 
on April 19, 2023.