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

 
We decided that the Plan does not have to pay for the office visits and related services provided on February 
27, 2023, to June 07, 2023. 
 
You asked the Plan to pay for the office visits and related services. You say that you say that the service was 
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 the office visits and 
related services provided on February 27, 2023, to June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and related features and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related features and accessories. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
rules for coverage of a Group 3 power wheelchair have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 standard power wheelchair with multiple power options (K0861) and related features and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect (0012M) provided June 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of CxBladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CxBladder panel remains unproven at this time. 
 
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 the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder Detect (0012M) provided June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect test (0012M) provided June 14, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of CxBladder Monitor as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CxBladder panel remains unproven at this time. 
 
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 the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder Detect test (0012M) provided June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 13, 2023, billed with 
procedure code 99213-24-57. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has not been reported with the 
appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed and reported with modifier 25. 
 We looked at the file and Medicare rules. We have confirmed that the billed service was not reported with the 
appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on July 13, 2023, billed with procedure code 99213-24-57.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect (0012M) provided May 16, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of CxBladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CxBladder panel remains unproven at this time. 
 
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 the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder Detect (0012M) provided May 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nuclear stress test injection provided 
on June 19, 2023. 
 
You asked the Plan to waive the coinsurance for the nuclear stress test injection. You say that the medical drug 
is the stress test itself. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the nuclear stress test injection. This item/service falls within 
the Medicare Part B prescription drugs 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 $49.59 ($247.96 allowed amount x 20% = $49.59). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the nuclear stress test injection 
provided on June 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the immune globulin injection home 
infusion provided on July 01, 2023, to July 22, 2023. 
 
You asked the Plan to waive the coinsurance for the immune globulin injection home infusion. You say that 
your home infusion therapy should be covered 100%. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the immune globulin injection home infusion. This 
item/service falls within the Medicare Part B prescription drugs 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 $926.88 ($4,634.40 allowed 
amount x 20% = $926.88) Therefore, we decided that the Plan does not have to waive the coinsurance for the 
immune globulin injection home infusion provided on July 01, 2023, to July 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 28, 2023. 
 
You asked the Plan to pay for the home visit. 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 home visit provided 
on March 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
August 15, 2022, to August 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
paying 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 $350 
copayment for each Medicare-covered hospital stay. 
 
You have been asked to pay a $350 copayment for an inpatient hospital stay. This item/service falls within the 
each Medicare-covered hospital stay 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 inpatient hospital stay provided on August 15, 2022, to August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure (enteral formula). 
 
You asked the Plan to pre-approve Ensure. You say that you are very sick. The Plan denied your request. The 
Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral formula is not covered when orally 
administered.  
 
We looked at the file and Medicare rules. Review of the file shows that the requested Ensure is for oral 
administration. This item is specifically not covered. Based on this information, we decided that Medicare rules 
for coverage of Ensure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ensure (enteral formula).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 02, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you visit was a post op 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scans to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve duplex scans. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that there are in-network providers available who can perform these services. 
 
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 
duplex scans to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 72 miles.  
 
You asked the Plan to pre-approve an additional 72 miles. You say that you are appealing as the authorization 
for the request got denied. The Plan denied your request. The Plan says your benefit only allows 50 miles. The 
Plan also says that you have exceeded your benefit limit. 
 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 50 miles for each one way trip.  
 
We looked at your request, the records in the case file, and the rules. The Plan rules say that they only cover 50 
miles of driving distance for each one-way trip. The record shows that the requested mileage is 72 miles for 
each one way trip, which is more than the allowed amount. Based on this information, we decided that the 
requested services have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve an additional 72 miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested repairs are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that repairs of durable medical equipment (DME) is 
only covered for certain indications. If the expense for repairs exceeds the estimated expense of purchasing or 
renting another item of equipment for the remaining period of medical need, no payment can be made for the 
amount of the excess. 
 
We looked at the file and Medicare rules. Review of the file shows that the repairs costs are approximately 
$1792.16. The replacement cost would be approximately $985.19. This means the repairs costs exceed the 
replacement costs. In this case, the repairs of the current wheelchair are not covered. Based on this information, 
we decided that Medicare rules for coverage of wheelchair repairs have not been met. Therefore, we decided 
that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 29, 2023. 
 
You asked the Plan to pay for the ambulance services. 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 ambulance services 
provided on March 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visits provided on July 
18, 2023, to August 14, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visits. You say that you cannot afford to 
pay the billed amount for the physical therapy visits. 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 the physical therapy visits. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total you owe is $150 ($30 copayment x 5 visits = $150). Therefore, we 
decided that the Plan does not have to waive the copayment for the physical therapy visits provided on July 18, 
2023, to August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care and the the debridement 
procedure provided on June 13, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care and the the debridement procedure. 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 subsequent nursing 
facility care and the the debridement procedure provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic services provided on June 23, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient clinic services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says their original decision to deny payment was correct.  
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 outpatient clinic services provided on June 23, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotic. 
 
You asked the Plan to pre-approve foot orthotic. You say that you were advised by your provider that this shoe 
insert is supposed to help correct your left foot. 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 pre-approve foot orthotic.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on June 
15, 2023. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that the injection was 
medically necessary. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 amount you owe is $276.24 ($1,381.20 allowed amount x 20% = 
$276.24). Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab 
injection provided on June 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 29, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you cannot afford 
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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room 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 the emergency room 
services provided on July 29, 2023.