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

 
We decided that the Plan does not have to reduce the copayment for an in-network Magnetic Resonance 
Imaging (MRI) of the spine provided on December 31, 2022. 
 
You asked the Plan to reduce the copayment for an in-network Magnetic Resonance Imaging (MRI) of the 
spine. You say that you do not feel its fair to be charged this copayment, as you were unaware of the difference 
between the MRI types. 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 diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for an in-network Magnetic Resonance Imaging (MRI) of the 
spine. This item/service falls within the diagnostic radiology 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. You have been asked to pay the 
allowed amount of $215.49 which is less than the $250 copayment for an in-network Magnetic Resonance 
Imaging (MRI) of the spine. Therefore, we decided that the Plan does not have to reduce the copayment for an 
in-network Magnetic Resonance Imaging (MRI) of the spine provided on December 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says the enrollee's needs can be met with 
less frequent therapy services in a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
with advanced imaging services provided on January 04, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit with advanced 
imaging services. You say that your issue was not resolved at the ER, you should not have to cover this cost. 
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 $200 
copayment for emergency care. 
 
You have been asked to pay a $200 copayment for an in-network emergency room (ER) visit with advanced 
imaging services. 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 copayment for an in-network emergency room (ER) visit with advanced imaging services 
provided on January 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair and excision provided on November 29, 2022. 
 
You asked the Plan to pay for repair and excision. 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 repair and excision 
provided on November 29, 2022.
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 05, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that your records show that an 
approved authorization exists. 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 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says the enrollee's needs may be met in a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and panoramic radiographic 
image (D0150, D0330) provided on December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and panoramic 
radiographic image (D0150, D0330) provided on December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services  provided on August 29, 2022 to 
September 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health aide services. You say that you have enclosed the physician's 
orders requiring home health care for review. You also say that this is causing an undue financial burden due to 
the payments were paid out-of-pocket. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. Services need to be provided in our network in order to be covered, unless they are urgent 
care, emergency care, or out-of-area renal dialysis. 
 
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 home health aide services  provided on August 29, 
2022 to September 18, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve the HFCWO device. You say that the enrollee needs aggressive airway 
clearance therapy as they are not able to effectively mobilize their secretions on their own. The Plan denied 
your request. The Plan says the enrollee does not have a qualifying disease or condition and does not meet the 
requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation system (HFCWO) (E0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 04, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are in-network, this should be covered 
without issue or delay. 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 laboratory services 
provided on November 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucleophosmin (Npm1) genetic testing (81310).  
You asked the Plan to pre-approve genetic testing. You say that you are writing to appeal testing for next 
generation sequencing. The enrollee has a history of Npm1 acute myeloblastic leukemia (AML) and currently 
in remission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria as 
the enrollee is in remission and has had this test completed already. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per National Coverage Determination (NCD) Next Generation 
Sequencing (NGS) 90.2 states that coverage of NGS as a diagnostic laboratory test is reasonable and necessary 
and covered nationally for patients who have not been previously tested with the same test using NGS for the 
same cancer genetic content. The documentation provided shows that the enrollee has been previously tested 
with the same test using NGS for the same cancer genetic content. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nucleophosmin (Npm1) genetic testing (81310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a large volume ultrasonic nebulizer system (E0575). 
 
You asked the Plan to pre-approve a large volume ultrasonic nebulizer system. You say that the enrollee has a 
history of experiencing shortness of breath and requires a nebulizer machine to properly and safely administer 
albuterol nebulizer treatments. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a large volume ultrasonic nebulizer system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a large volume ultrasonic nebulizer system (E0575).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that your current machine is broken, and you are 
requesting a replacement. The Plan denied your request. The Plan says this device is only eligible once every 5 
years 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have E0601. The 5-year reasonable lifetime use does not expire until October 30, 2023. 
E0601 serves the same purpose as the CPAP device. Therefore, we decided that the Plan does not have to pre-
approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 02, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
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 $5 
copayment for outpatient diagnostic tests/laboratory tests. 
 
You have been asked to pay a $5 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/laboratory 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 copayment 
for laboratory services provided on July 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and injection provided on July 12, 2022. 
 
You asked the Plan to pay for the office visit and injection. You say that previous claims for this enrollee have 
been paid. 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 office visit and 
injection provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental cleaning (D1110) provided on December 15, 2022. 
 
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 that your benefit for the service provided has 
already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence provided showing your benefit for the service provided was previously 
exhausted. Therefore, we decided that the Plan has to pay for the dental cleaning (D1110) provided on 
December 15, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical 
spine (72141) 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that an MRI is necessary to evaluate 
the cause of the enrollee's pain and weakness. The Plan denied your request. The Plan says the request does not 
meet the Medicare or Plan coverage criteria. 
 
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 an MRI of the cervical spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. The provided exam did not document objective cervical spine issues. The appeal 
letter stated the enrollee has neck pain, severe kyphosis and has had complaints of radiculopathy ongoing for 
several years. This is not corroborated by any other documentation provided. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested imaging study in this clinical setting. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the MRI of the cervical spine (72141), in this case, is not medically 
reasonable and 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 an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided on November 15, 2022. 
 
You asked the Plan to pay for an inpatient stay. You say that this was medically necessary and 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 an inpatient stay 
provided on November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 20, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you received an electrocardiogram 
on this date. 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 $160 
copayment for in-network outpatient diagnostic radiology, including ultrasounds. 
 
You have been asked to pay a $160 copayment for the ultrasound. This item/service falls within the in-network 
outpatient diagnostic radiology, including ultrasounds 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 records show an ultrasound was provided on December 20, 
2022. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on 
December 20, 2022.