Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and these procedures are 
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 February 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and 
mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on April 17, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on April 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an MRI provided on July 5, 2022. 
 
You asked the Plan to waive the coinsurance for an MRI. You say that the copayment is too high. 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 up to $75 per day for Medicare covered diagnostic radiology services.  
 
 
  You have been asked to pay $75 for an MRI. 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an MRI provided on July 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 81231, 81232, 81306, 
81328, 81355, 81401, 81406, 81230, 0031U, 0032U, 0033U, 81240, 81241, and 81291, provided on July 27, 
2022. 
 
You asked the Plan to pay for the laboratory services. 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. Additionally, panel testing should be billed using one CPT code 
on the claim. 
 
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. The rules also say that if one laboratory 
procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall 
report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, 
multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Additionally, this was an NGS panel that was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 
81231, 81232, 81306, 81328, 81355, 81401, 81406, 81230, 0031U, 0032U, 0033U, 81240, 81241, and 81291, 
provided on July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 28, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the provider has no prior knowledge of the 
patients they will be required to see. 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 skilled nursing facility 
provided on March 28, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
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 pre-approve the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found a recent ultrasound of the abdomen showed no 
abdominal wall fluid collection but due to the leg edema and ulcerations together with the history of 
hemoptysis the request for CT of the abdomen and pelvis is reasonable to look for a cause of venous 
obstruction within the abdomen and pelvis especially in this patient with prior abdominal surgery. 
 
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 pre-
approve a computed tomography (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 receiver and sensors. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 receiver and sensors. You say that you do not agree with 
the denial of the Freestyle Libre 3. The Plan denied your request. The Plan says the Freestyle Libre 3 has been 
denied. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 receiver and sensors.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic colonography (CTC). 
 
You asked the Plan to pre-approve the CTC. You say that the denial letter stated the same test would be 
approved if requested. 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 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 the CTC. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found On last encounter of July 14, 2022, it was 
discussed that the patient is a high surgical risk patient due to Supra ventricular tachycardia and chronic 
obstructive pulmonary disease (COPD). He has never had a colonoscopy. At that last encounter it was 
mentioned that the patient would be evaluated by a cardiologist and pulmonologist to evaluate his surgical risk. 
Those consultations and opinions are not in the submitted records. If those evaluations indicate an unacceptable 
anesthesia risk for direct colonoscopy the requested CT colonography would be reasonable especially given the 
positive Cologuard results. Absent such information the medical necessity of the requested CT colonography 
has not been established in the submitted records. 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 CTC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic colonography (CTC).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
from April 14, 2023, to April 16, 2023. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you were taken 
by ambulance and admitted by the emergency room physician who felt it was medically necessary. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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.  
 
The rules also 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 $95 copayment for emergency care.  
 
You have been asked to pay a $95 copayment for an ER visit. This item/service falls within the emergency care 
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 cost for an ER visit and self-administered drugs 
provided from April 14, 2023, to April 16, 2023.  
 
Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the associated 
administration services provided on March 24, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the associated administration 
services. You say that you disagree with the cost share applied. 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 outpatient diagnostic tests. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and the associated administration 
services. 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 $327.02, which is 
20% of the allowed amount for chemotherapy drugs and the associated administration services ($1,635.11 
allowed x 20% = $327.02). Therefore, we decided that the Plan does not have to waive the coinsurance for 
chemotherapy drugs and the associated administration services provided on March 24, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of a lower extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that the services are 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 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 medically necessary. Our physician reviewer found you have a soft tissue mass medial aspect left 
knee with negative plain films. The request for MRI of the left knee in the face of a palpable soft tissue mass is 
reasonable since soft tissue sarcoma would be in the differential. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of a lower extremity joint.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
February 2, 2023. 
 
You asked the Plan to pay for the dental service. You say that the previous x-rays were blurry, so the provider 
needed to take new x-rays. 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 the Plan paid for a panoramic radiographic image (D0330) on April 1, 2022; therefore, your benefit for 
the requested item or service was exhausted on the date of service of April 1, 2022. Therefore, we decided that 
the Plan does not have to pay for a panoramic radiographic image (D0330) provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on March 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the specialist office visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the specialist office visit provided on March 1, 
2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found documentation 
doesnt support that the enrollee requires additional skilled nursing services to provide treatment that is 
medically necessary. The enrollee does not require additional skilled nursing services to effectively provide 
treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance program to 
maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 29, 2022. 
 You asked the Plan to pay for the lab services. You say that the coding and diagnosis codes were correct. 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 lab services provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided in at an outpatient hospital facility provided on March 31, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan provided in at an outpatient 
hospital facility. You say that you already paid $40 and you are not sure what the additional copayment is for. 
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 $225 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $225 copayment for a computed tomography (CT) scan provided in at an 
outpatient hospital facility. 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 
$97.90, which is less than the standard copayment for advanced imaging services, including CT scans. 
Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) 
scan provided in at an outpatient hospital facility provided on March 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) 
provided on February 24, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging (MRI). You say that you were 
not advised on how much the MRI would cost but assumed it was only a $40 copayment for a specialist visit. 
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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a magnetic resonance imaging (MRI). 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 $245.92, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to reduce the copayment for a magnetic resonance 
imaging (MRI) provided on February 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) service 
provided on January 24, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) service. You say that you already 
paid the $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 $35 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for each physical therapy (PT) service. 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 you owe is $70 for the PT visits ($35 per visit x 2 visits = $70). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) 
service provided on January 24, 2023, to January 31, 2023.