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

 
We decided that the Plan does not have to waive the copayment for EKG provided on June 01, 2023. 
 
You asked the Plan to waive the copayment for EKG. You say that you say that you want to know why you 
have been charged for the EKG. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for EKG. 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. However, since the allowed amount is less than the standard copayment, 
you only owe $11.34. Therefore, we decided that the Plan does not have to waive the copayment for EKG 
provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown repair (D2980), core buildup (D2950), endodontic 
therapy (D3330), interim crown (D2799), clinical crown lengthening (D4249), unspecified adjunctive 
procedure (D9999), extraction of an erupted tooth or exposed root (D7140), bone graft at time of implant 
placement (D6104), surgical placement of implant body (D6010), a porcelain crown (D2750), and implant 
supported porcelain/ceramic crown (D6065) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental work was approved for the United 
States so it should be approved anywhere because you feel it was an emergency. The Plan denied your request. 
The Plan says that your plan does not cover care performed outside of the U.S. unless it is an emergency. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from outside of the United States. Therefore, we decided that the Plan does not have 
to pay for a crown repair (D2980), core buildup (D2950), endodontic therapy (D3330), interim crown (D2799), 
clinical crown lengthening (D4249), unspecified adjunctive procedure (D9999), extraction of an erupted tooth 
or exposed root (D7140), bone graft at time of implant placement (D6104), surgical placement of implant body 
(D6010), a porcelain crown (D2750), and implant supported porcelain/ceramic crown (D6065) provided on 
April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you need these inserts so you can walk. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ReliON Platinum blood glucose meter. 
 
You asked the Plan to pre-approve a ReliON Platinum blood glucose meter. You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a ReliON Platinum blood glucose meter. Therefore, we decided that the Plan does not have to pre-approve a 
ReliON Platinum blood glucose meter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 31, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on March 31, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional partial upper denture (D5820) provided on May 
19, 2023. 
 
You asked the Plan to pay for transitional partial upper denture. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
transitional partial upper denture (D5820) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 26, 2023. 
 
You asked the Plan to pay for a consultation. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on July 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay, a CT scan, and 
an MRI provided from March 11, 2023, to March 28, 2023. 
 You asked the Plan to waive the copayments for an inpatient hospital stay, a CT scan, and an MRI. You say 
that you have met your maximum out-of-pocket but keep receiving bills. 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 $325 
copayment each day for days 1 to 5 per admission and $0 copayment for additional days for inpatient hospital 
care and a $105 copayment for Medicare-covered radiological diagnostic services, not including x-rays.  
 
You have been asked to pay a $1,835 copayment for an inpatient hospital stay, a CT scan, and an MRI. This 
total includes a $1,625 copayment for an inpatient hospital stay ($325 per day x 5 days = $1,625), a $105 
copayment for a CT scan, and a $105 copayment for an MRI. The inpatient stay falls within the inpatient 
hospital care benefit category. The CT scan and MRI fall within the outpatient diagnostic tests benefit category. 
Your maximum out-of-pocket of $3,500 was not met at the time services were rendered. 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 an inpatient hospital stay, a CT scan, and an MRI provided from 
March 11, 2023, to March 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on October 10, 
2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are asking for a 
reconsideration of the copayment from $20 to $0. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. 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. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided on October 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way transportation trips when each one-way trip does not exceed 
50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Atriclip exclusion of left atrial appendage (33269). 
 
You asked the Plan to pre-approve Atriclip exclusion of left atrial appendage. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is considered investigational or experimental 
and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Atriclip exclusion of left atrial 
appendage. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found in this patient, authorization for the performance of a 
convergent hybrid ablation procedure would be considered appropriate and reasonable in this patient's clinical 
management, and in fact it has been pre-approved. As such, it would also be reasonable, at the discretion of the 
surgeon, to carry out at the same time, left atrial appendage exclusion using the Atriclip, not as a stand-alone 
procedure, but as an accompaniment to the epicardial ablation procedure, as the heart will be exposed and the 
procedure thereby facilitated, without significant added risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Atriclip exclusion of left atrial appendage have been met. Therefore, we decided 
that the Plan has to pre-approve Atriclip exclusion of left atrial appendage (33269).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 30, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this extensive of testing was neither reasonable nor 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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on March 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for the evaluation and treatment of hemorrhoids, in absence of 
other covered indications. 
 
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 a colonoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has known hemorrhoids and he is up to date for colorectal cancer screening, so 
colonoscopy is not medically necessary and does not meet criteria for coverage. 
 
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the IGRT. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says picture studies are not supported to guide this type of treatment. 
 
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 the IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is Food 
and Drug Administration (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 (77280- also requested in this case) and/or IGRT for a technology for which need has not been established by published data or supported by consensus guidelines is 
not 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 IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs provided from June 17, 2023, to 
June 19, 2023. 
 
You asked the Plan to pre-approve the medication. You say that you feel the Plan should pay for the self-
administered drugs. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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. Therefore, we decided that the Plan does not have to pre-approve self-administered drugs 
provided from June 17, 2023, to June 19, 2023.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454) for the left knee. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee is unable to perform 
daily tasks without being in constant pain. You also say that the enrollee is a fall risk. The Plan denied your 
request. The Plan says this service is considered experimental and therefore is not covered. 
 
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 the genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental/investigational therapy as additional research is 
needed. Therefore, the reviewer found that the requested genicular nerve block is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance, when performed (64454) for the left knee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on January 04, 
2023, to July 17, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were unaware of any 
copayments for each 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 $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for physical therapy. 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. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided on January 04, 2023, to July 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that your family has a history of heart attacks, so the 
requested CT scan is medically necessary. The Plan denied your request. The Plan says the requested CT scan 
is not medically necessary. 
 
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 
CT scan is not medically reasonable or necessary. Our physician reviewer found that Medicare does not cover a 
cardiac CT as a screening tool in the absence of signs, symptoms, or disease. 
 
  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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.