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

 
We decided that the Plan does not have to pay for the computed tomography (CT) scans provided on October 
25, 2022. 
 
You asked the Plan to pay for the computed tomography (CT) scans. 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 computed 
tomography (CT) scans provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on July 
10, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you do not feel 
responsible for this bill. 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 in-network provider and professional services provided in a specialists office. 
 
You have been asked to pay a $45 copayment for a new patient office visit. This item/service falls within the 
in-network provider and professional services provided in a specialists office 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 new patient office visit provided on July 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
additional PT visits.   
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 the enrollee's 
condition. Our physician reviewer found the enrollee has been receiving ongoing PT since September 19, 2023. 
The enrollee continues to require minimal assistance with daily tasks and use a walker for assistance with 
ambulation. The enrollees level of mobility and function has remained unchanged, and their motor strength is 
the same. The enrollee can continue with strengthening exercises in the context of a home exercise program, 
and this does not require the services of a skilled physical therapist. Therefore, the 10 additional PT visits are 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the compression stocking to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the compression stocking. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says this service is available with in-
network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the compression stocking to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression garment system to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve a compression garment system. You say that you are requesting 
reconsideration of the denied items. The Plan denied your request. The Plan says the items were not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a compression garment system to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 16, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 service 
provided on March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery provided on May 31, 
2023. 
 
You asked the Plan to waive the cost share for outpatient surgery. You say that you disagree with the 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. Your 
contract with the Plan says that there is a $600 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. You are being asked to pay $131.03 towards your $600 deductible. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $600 deductible which applies to outpatient surgery. 
This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was received 
on May 31, 2023. Therefore, we decided that the Plan does not have to waive the cost share for outpatient 
surgery provided on May 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the coinsurance for outpatient surgery on April 12, 2023, 
to April 19, 2023.  
 
You asked the Plan to reimburse the coinsurance for outpatient surgery. You say that no one in the office 
indicated that the provider was out-of-network. 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% 
coinsurance for each Medicarecovered outpatient surgery at an outpatient hospital facility. 
 
 You have been asked to pay a 35% coinsurance for each outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 
Plan verified that the provider is out-of-network. Therefore, we decided that the Plan does not have to 
reimburse the coinsurance for outpatient surgery on April 12, 2023, to April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network outpatient surgery 
provided on June 15, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network outpatient surgery. 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 45% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 45% coinsurance for an out-of-network outpatient surgery. This item/service falls 
within the out-of-network outpatient surgery 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 out-of-network outpatient surgery provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic shoes with inserts and shoe modification 
 You asked the Plan to pre-approve the diabetic shoes with inserts and shoe modification. You say that your 
previous pair of shoes are worn out and you need a new pair of shoes. The Plan denied your request. The Plan 
says your benefit for the requested items or services has already been exhausted. 
 
Medicare rules state coverage is limited to 1 pair of diabetic shoes within 1 calendar year. The Plan follows 
these same rules. 
 
We looked at the file, the Plan's coverage and Medicare rules. The record shows your benefit for the requested 
items or services was exhausted on date of service of February 14, 2023. Therefore, we decided that the Plan 
does not have to pre-approve the diabetic shoes with inserts and shoe modification
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network diagnostic heart test 
provided on May 01, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network diagnostic heart test. You say that you were 
never advised that there would be a copayment or 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 20% 
coinsurance for outpatient diagnostic testing. 
 
You have been asked to pay 20% coinsurance for an in-network diagnostic heart test. This item/service falls 
within the outpatient diagnostic testing 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 $409.19 ($2045.93 x 20% = $409.19). Therefore, we 
decided that the Plan does not have to waive the coinsurance for an in-network diagnostic heart test provided 
on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and related services 
provided on July 07, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that authorization 
is not required. 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 subsequent nursing 
facility care, and related services provided on July 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on April 28, 2023. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you are asking the plan to review 
and remove the charge that was applied as your copay responsibility. 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 $245 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $245 copayment for an endoscopy. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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. However, since 
the allowed amount is less than the standard copayment, you only owe $233. Therefore, we decided that the 
Plan does not have to waive the copayment for an endoscopy provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, and 
cleaning (D1110, D0274, D0120) provided on June 22, 2023. 
 
You asked the Plan to pay more 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 June 22, 2023. Therefore, 
we decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, and cleaning 
(D1110, D0274, D0120) provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network tomographic heart scan 
provided on June 20, 2023. 
 
You asked the Plan to waive the copayment for an in-network tomographic heart scan. You say that you were 
never advised on this 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 $220 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $220 copayment for an in-network tomographic heart scan. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network tomographic heart scan provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87653, 87798, and 87801) provided 
on December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered 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 87481, 87653, 87798, and 87801 are not supported in the medical record. Specifically, 
a panel was performed and there is a more appropriate singular code for the services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing (87481, 87653, 87798, and 87801) provided on 
December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic counseling services to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the genetic counseling services. You say that you are requesting 
reconsideration of the denied services. The Plan denied your request. The Plan says the services were not 
approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the genetic counseling services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external patient provided on January 27, 2023. 
 
You asked the Plan to pay for external patient. You say that this service is supported in the records. 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 external patient provided 
on January 27, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an arthroscopic knee meniscectomy including chondroplasty 
(29881).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of the 
requested service as she has severe osteoarthritis.   
 
The Plan follows Medicare rules. Medicare rules say that Arthroscopic debridement and lavage with or without 
debridement for patients presenting with severe osteoarthritis 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 this service. Our reviewer says that the 
enrollee meets criteria for coverage of the requested service. Our physician reviewer found that the enrollee 
was being treated for a medial meniscal tear and osteoarthritis of the left knee. She presented with left knee 
pain and left knee primary osteoarthritis with an underlying longitudinal horizontal medial posterior horn 
meniscal tear. The exam reveals painful range of motion. She has an antalgic gait. There is crepitation with 
motion. The McMurrays test is positive. There is pain with palpation of the medial joint line. On July 11, 
2023, the x-rays of the left knee have findings of varus osteoarthritis; medial joint space narrowing, sclerosis, 
osteophytes present with severe varus overall alignment; and varus osteoarthritis of the left knee. Based on the 
noted scale, the osteoarthritis that is supported by documentation would be Kellgren-Lawrence grade 2. This is 
noted to be minimal osteoarthritis. The overall combination of findings supports that the enrollee has a mild-
moderate level of left knee osteoarthritis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Specifically, the plan has denied this service based 
on the enrollee having severe osteoarthritis.  
  
 
 
However, our reviewer found that the enrollees osteoarthritis does not rise to the level of severe. Therefore, we 
decided that the Plan has to pre-approve an arthroscopic knee meniscectomy including chondroplasty (29881).   
 
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.