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

 
We decided that the Plan does not have to pay for wound care provided on January 09, 2023. 
 
You asked the Plan to pay for wound care. You say that you believe the services are 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 wound care provided on 
January 09, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography. 
 
You asked the Plan to pre-approve polysomnography. 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 all reasonable and necessary diagnostic tests 
performed by sleep disorder clinics (Sleep Disorder Centers or Laboratories for Sleep Related Breathing 
Disorders) given for the medical conditions listed under Medical Conditions for Which Testing is Covered are 
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 polysomnography. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found an attended polysomnogram is not 
medically necessary. This enrollee has a known diagnosis of obstructive sleep apnea and has been using bilevel 
positive airway pressure (BiPAP) successfully for many years. The current device is more than 10 years old 
and is coming apart. There are no new symptoms of obstructive sleep apnea, and the enrollee is using and 
benefiting from the device. The Epworth score is 2. Apnea-hypopnea index (AHI) is 1.2. Compliance is 96.7%. 
Medicare does not require a sleep study in order to obtain a replacement device, when the device is more than 5 
years old and no longer fully functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 02, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 home visit provided on 
December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that you do not wish to be cut 
on and would prefer this treatment instead. The Plan denied your request. The Plan says the requested service is 
not covered by Medicare or the health plan. There is not enough evidence that this type of radiation therapy 
guidance is needed or effective for your skin cancer. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to you for which the 
target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a 
need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound though that 
in and of itself does not mean that daily imaging is necessary but simply that the device was designed to 
incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for 
which need has not been established by published data or supported by consensus guidelines (many of which 
recommend against treatment with these devices in general) is not necessary. The decision is unfavorable as 
billing for daily IGRT which would not be furnished in accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cystourethroscopy provided on 
February 06, 2023. 
 
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that you did not have a second 
copayment last year. 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 $20 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $20 copayment for the cystourethroscopy. This item/service falls within the in-
network outpatient hospital 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. Therefore, we decided that the Plan does not have to reduce the copayment for 
the cystourethroscopy provided on February 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in need of a NIV due to the 
severity of chronic respiratory failure secondary to COPD. The Plan denied your request. The Plan says a 
review of the current medical literature does not consider this device to be standard medical treatment for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD. There is no 
documentation of chronic CO2 retention. The Life2000 system is not a true ventilator, because it is not capable 
of providing full ventilatory support. There is inadequate evidence of the safety and efficacy of this device in 
the treatment of COPD. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 10, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that you do not understand why 
these services are not 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 and 
related services provided on January 10, 2023.
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 May 17, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were 
going to cancel the appointment after you were informed about the $150 copayment, but then was advised there 
would be no 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 $150 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $150 copayment for a computed tomography (CT) scan. 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 
computed tomography (CT) scan provided on May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for computerized tomography (CT) scan on 
February 13, 2023. 
 
You asked the Plan to waive the cost sharing for CT scan. You say that you say that you were told to get a 
follow up scan in six months. 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 $497 
cost share for low dose computed tomography (LDCT). There is no coinsurance, copayment, or deductible for 
the Medicarecovered counseling and shared decisionmaking visit or for the LDCT. For qualified individuals, 
a LDCT is covered every 12 months. The provider billed in the amount of $497, and this is also the allowed 
amount. Therefore, results in the total cost sharing amount of $497. You have been asked to pay $497 cost share for CT scan. This item/service falls within the screening for lung 
cancer with low dose computed tomography (LDCT) 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 sharing for computerized tomography (CT) scan on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the lumbar injections provided on October 
13, 2022, and January 19, 2023. 
 
You asked the Plan to waive the copayments for the lumbar injections. You say that you believe the charges 
have been coded wrong. 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 $375 
copayment for each in-network Medicare-covered outpatient surgery service in 2022. Your contract with the 
Plan also clearly says that you must pay a $395 copayment for each in-network Medicare-covered surgery 
service at an outpatient hospital facility in 2023. 
 
You have been asked to pay a $375 copayment for the lumbar injection provided on October 13, 2022. You 
have also been asked to pay a $395 copayment for the lumbar injection provide on January 19, 2023. You have 
been asked to pay a total of $770 ($375 copayment + $395 copayment = $770). These items/services fall within 
the outpatient surgery, including services provided at hospital outpatient facilities 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 copayments for the lumbar injections provided on October 13, 2022, and January 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the laboratory service provided on September 23, 2022. 
 
You asked the Plan to pay more for the lab service. You say that you would like the claim to be reprocessed for 
an additional payment. The Plan denied your request. The Plan says the claim has been processed 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $15 copayment for Medicare-covered lab services.  
 
 The enrollee has been asked to pay a $15 copayment for the lab service. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to pay more for the laboratory service provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on 
November 29, 2022. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that the amount being charged 
for this procedure has changed. 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 $360 
copayment for in-network outpatient hospital observation. 
 
You have been asked to pay a $360 copayment for the cystourethroscopy. This item/service falls within the in-
network outpatient hospital observation 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 $343. Therefore, we decided that the Plan does not have to waive the copayment for the 
cystourethroscopy provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for residence visit for evaluation provided on January 20, 2023. 
 
You asked the Plan to pay for residence visit for evaluation. You say that you say that the assisted living 
facility was responsible for 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 residence visit for 
evaluation provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient observation services 
provided on January 05, 2023, to January 06, 2023. 
 
You asked the Plan to waive the copayment for the outpatient observation services. You say that you do not 
think the services you received should be considered outpatient observation. 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 $350 
copayment for outpatient hospital observations. 
 
You have been asked to pay a $350 copayment for the outpatient observation services. This item/service falls 
within the outpatient hospital observations benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the outpatient observation services provided on January 05, 2023, to January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an intra-socket biological dressing to aid 
in hemostasis or clot stabilization, per site for teeth number 18 and 20 (D7922 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under your 
supplemental dental benefit policy. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve placement 
of an intra-socket biological dressing to aid in hemostasis or clot stabilization, per site for teeth number 18 and 
20 (D7922 x 2).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to reduce the coinsurance for the denosumab injection provided on February 6, 
2023. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that this is an excessive charge. The 
Plan denied your request. The Plan says that 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 enrollees must pay 20% coinsurance for each Medicare-covered Part B drug.  
 
The Plan says you must pay $276.80 coinsurance for the injection. Based on the Plan contract, however, you 
cannot be asked to pay more than $272.38, which is 20% coinsurance of the allowed amount for the injection 
($1,361.88 allowed amount x 20% =$272.38). Therefore, we decided that the Plan has to reduce the 
coinsurance for the denosumab injection provided on February 6, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on November 
24, 2022. 
 
You asked the Plan to pay for chronic care management services. You say that the enrollee could not choose an 
in-network provider. 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 chronic care 
management services provided on November 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were done on 3 separate teeth and not 
on the same tooth so they should not be denied. The Plan denied your request. The Plan says your benefit for 
the requested items or services 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 the intraoral radiographic image (D0220) on January 18, 2023; therefore, your benefit 
for the requested items or services was exhausted on the date of service of January 18, 2023. Therefore, we 
decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on January 
18, 2023.