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

 
We decided that the Plan does not have to pre-approve a SPECT scan for evaluation of possible Lewy Body 
dementia (78803 radiopharmaceutical localization of tumor with A9584 Iodine I-123 Ioflupane). 
 
You asked the Plan to pre-approve a SPECT scan. You say that this service is medically necessary. The Plan 
denied your request. The Plan says rules for pre-approval have not been met. 
 
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 SPECT scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that at the present time the current 
diagnostic criteria for Lewy Body Dementia (DLB) do not require the use of SPECT (or any form of 
neuroimaging) in order to reach a diagnosis of this condition. Such imaging has not been shown to be 
sufficiently specific to confirm or rule out DLB. Rather, the body of literature available does not readily permit 
conclusions on the net benefits to health outcomes associated with the requested imaging study/modality. In 
this context the requested services would not be the most appropriate service or supply that could be provided 
to the enrollee at this time. Rather, the enrollee could have a diagnosis made on the basis of history and clinical 
findings alone. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SPECT scan for evaluation of possible Lewy Body dementia (78803 
radiopharmaceutical localization of tumor with A9584 Iodine I-123 Ioflupane).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Velphoro chewable tablets. 
 
You asked the Plan to pre-approve Velphoro chewable tablets. You say that this medication has allowed the 
enrollee to maintain a safe phosphorus level. The Plan denied your request. The Plan says coverage of this 
medication is the responsibility of the enrollee's prescription drug 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 Velphoro chewable tablets.  
 
Benefits for Velphoro chewable tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure provided on June 1, 2020. 
 
You asked the Plan to pay for the preventive procedure. The Plan denied your request. The Plan says this 
service is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
preventive procedure provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you want continuity of care because 
you have been under the care of this physician for two decades and had removal of a growth in your intestine 
under his care. The Plan denied your request. The Plan says the service is available within the network and the 
member?s condition is not an emergency. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on June 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator rendered on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 23, 
2020, and August 10, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you regular lab was closed 
due to COVID-19 and had to stand outside in 113 degree heat. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 lab services provided at a freestanding laboratory. 
 
You received laboratory services at a freestanding laboratory on July 23, 2020. Therefore, you are responsible 
to pay the $20 copayment.   
 
You received laboratory services at a freestanding laboratory on August 10, 2020. Therefore, you are 
responsible to pay the $20 copayment.  
 
The total amount you owe is: $40.   
 
You have been asked to pay the total copayment amount of $40 for laboratory services. Laboratory services fall 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for laboratory services provided on July 23, 2020, and August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy, flexible, transoral; with 
esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed (CPT Code 43210). 
 
You asked the Plan to pre-approve the service. You say that this is a minimally invasive treatment for 
gastroesophageal reflux disease (GERD) that is performed in an outpatient setting and delivers outcomes 
similar to those provided by conventional anti-reflux surgical procedures but with less invasion, fewer adverse 
events and does not limit future treatment options. The Plan denied your request. The Plan says they consider 
this procedure to be investigational. The Plan states further research is needed in order to prove that there are 
benefits and no safety concerns with this procedure. The Plan states treatments or tests that are investigational 
are not considered medically necessary and reasonable and as result, not covered by the member's insurance. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although TIF is a standard endoscopic treatment for GERD for an appropriate patient, there are 
some general exclusions that have not been well studied, including BMI less than 35, Barrett's esophagus with 
dysplasia or a hiatal hernia less than 2 cm. This patient has GERD refractory to medication but is also reported 
to have a concomitant hiatal hernia of 3 cm, TIF has not been investigated sufficiently in patients with hiatal 
hernias of 3 cm or greater and generally this may decrease effectiveness of TIF and increase the likelihood of 
treatment failure. Medical necessity of the requested procedure is therefore not determined at this time. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, 
partial or complete, includes duodenoscopy when performed (CPT Code 43210).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observational hospital care provided on January 6, 2020. 
 
You asked the Plan to pay for observational hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says original Medicare is responsible for payment under the fee-for-
service benefit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for observational hospital care provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased July 23, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in-network provider. 
 
We looked at this physician's review, the file, and the Plan's rules. In this case, the hearing aids were purchased 
from an out-of-network provider. Prior authorization was not obtained for the service. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids purchased July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee needs a CGM. The Plan
denied your request. The Plan says the enrollee can use the Plan's preferred brand of CGMs.
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. The Plan contract states that the Plan only covers FreeStyle Libre Continuous
Glucose Monitors (GGMs).
We looked at the file and Medicare rules. The submitted medical records do not document any medical reason
the enrollee's needs would not be met by the Plan's preferred brand of CGMs. Based on this information, we
decided that Medicare rules for coverage of a Dexcom G6 CGM have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 10, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these
services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 10, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Pl
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve these services. You say that you use the gloves for application of treatments 
for dry skin and back pain. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on June 15, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you think this is being billed 
incorrectly. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $110 copayment for an ultrasound. The correct copayment has been applied to 
the ultrasound that was provided. An ultrasound falls within the outpatient diagnostic tests/radiological 
diagnostic 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 an ultrasound 
provided by a participating provider on June 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a 
participating provider on July 9, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you had authorization for this. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
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 $95 
copayment for outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $95 copayment for an MRI. These services were not denied; therefore, the 
correct copayment has been applied. An MRI falls within the outpatient diagnostic tests/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. Therefore, we decided that the Plan does not have to waive the copayment for diagnostic radiology 
services provided by a participating provider on July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON physical therapy services. You say that this provider is the only 
physical therapy clinic in the county. The Plan denied your request. The Plan says there are in-network 
providers within a reasonable distance of the enrollee's home. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 6, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 out of network services 
provided to the enrollee on June 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on July 
2, 2020 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 out of network lab services 
provided to the enrollee on July 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services other than manual manipulation of the 
spine provided to the enrollee on February 19, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the services provided are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services other than manual manipulation of the spine provided to 
the enrollee on February 19, 2020.