Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you are in a lot of pain. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested services are not generally accepted as specific and 
effective therapy for your condition. You have had extensive therapy and the records do not demonstrate that 
the unique skills of a professional therapist are required to safely and effectively provide treatment or that the 
services can be performed only by a therapist or under the supervision of a therapist. You have been instructed 
in a home exercise program. The services are not part of a maintenance program and you do not need the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or slow deterioration of your condition. Further physical 
therapy services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the MRI, the elastography, and the Part B 
injection provided on July 30, 2020. 
 
You asked the Plan to reduce the cost share for the MRI, the elastography, and the Part B injection. You say 
that that both scans were performed while you were in the tube. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $115 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic) and 20% 
each Medicare-covered Part B drug.  
 
You have been asked to pay a total of $259.48 for the MRI, the elastography, and the Part B injection. The 
MRI and the elastography fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The Part B injection falls within Medicare Part B Prescription Drugs benefit category. See 
chart below. 
  
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
July 30, 2020 MRI $363.79 $115 $115 
July 30, 2020 Elastography $134.49 $115 $115 
July 30, 2020 Part B injection $147.40 20% $29.48 
Total    $259.48 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the cost share for the MRI, the elastography, and the Part B injection provided 
on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alpha stim unit. 
 
You asked the Plan to pre-approve an alpha stim unit. You say that you want to receive these services that you 
feel are needed for help with sleep. The Plan denied your request. The Plan says this service is not currently 
covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of an alpha stim unit have not been met. Medicare guidance says no 
program payment may be made for electrosleep therapy. Until scientific assessment of this technique has been 
completed and its efficacy is established, no program payment may be made for electrosleep therapy. 
Therefore, we decided that the Plan does not have to pre-approve an alpha stim unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay, each 
(CPT Code L3216). 
 
You asked the Plan to pre-approve the orthopedic footwear. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the item is not covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthopedic footwear have not been met. After review, it was 
determined that an orthopedic footwear, ladies shoe, depth inlay, each (L3216) is not a covered Medicare item. 
Per Local Coverage Article: Orthopedic Footwear - Policy Article (A52481), shoes, inserts, and modifications 
are covered in limited circumstances. They are covered in select beneficiaries with diabetes for the prevention 
or treatment of diabetic foot ulcers. However, different codes are used for footwear provided under this benefit. 
The LCA goes on to list covered Medicare codes and states with the exception of the listed covered codes, 
orthopedic footwear billed using code, L3216 will be denied as non-covered. Therefore, we decided that the 
Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay, each (CPT Code L3216).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental biopsy (D7286) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is not covered under the benefit package. 
 
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 pre-approve a 
dental biopsy (D7286) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incision for implantation of cranial nerve (eg, vagus 
nerve) neurostimulator electrode array and pulse generator (CPT Code 64568) and insertion of chest wall 
respiratory sensor electrode or electrode array, including connection to pulse generator (0466T). 
 
You asked the Plan to pre-approve the services. You say that you have tried several masks and are unable to 
tolerate continuous positive airway pressure (CPAP). The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. In this case, your body mass index 
(BMI) is 36.5. While this procedure may be beneficial for you, the Medicare coverage rules for placement of 
the hypoglossal nerve stimulator are not met. Therefore, we decided that the Plan does not have to pre-approve 
incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 
(CPT Code 64568) and insertion of chest wall respiratory sensor electrode or electrode array, including 
connection to pulse generator (0466T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (22899, C9752 and C9753). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Iliac crest bone graft is the gold standard procedure. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (22899, C9752 and C9753).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for amputation surgery with an out-of-network 
provider for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation provided to justify the necessity of an out-of-network 
provider. 
 
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 
a referral for amputation surgery with an out-of-network provider for the enrollee.
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 records provided support that IRF care is 
medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF setting 
have not been met. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided 
at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollee's care needs can be met at a lower 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided September 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not request this service. 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 September 16, 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 Plan does not have to pay for the ambulance services provided on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 28, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims must be billed with 
TOB 13x. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required TOB 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 28, 
2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found given the 
inability to tolerate such contrast CT scans of soft tissues including chest wall, liver, adrenals etc. is very 
limited as post contrast evaluation is critical in tumor patients. Absent the ability to rely on CT imaging 
PET/CT would be the optimal way to evaluate this enrollee. 
 
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 PET CT scan from the skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and related services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and related services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a network provider. 
 
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 
an office visit and related services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 8, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 a hospital outpatient clinic visit provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) and breast 
ultrasound (76641-LT) received February 14, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit and breast ultrasound. You say that your 
contract should cover all charges The Plan denied your request. The Plan says copayment amounts were 
applied 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 each covered specialist office visit and a $50 copayment for each covered x-ray in a provider's 
office. 
 
You have been asked to pay a $45 copayment for a specialist office visit. Specialist office visits fall within the 
Physician/Practitioner services, including doctor's office visits benefit category. You also have been asked to 
pay a $50 copayment for an ultrasound. Ultrasounds fall within the Outpatient diagnostic tests and therapeutic 
services and supplies category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit 
(99203) and breast ultrasound (76641-LT) received February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 4, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you 
were proactive in trying to obtain authorization for the claim. The Plan denied your request. The Plan says 
these services were not urgent, emergent or authorized by the Plan. 
 
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 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 the medical services provided on September 4, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a brace (L0457) provided August 7, 2020. 
 
You asked the Plan to pay for the brace. You say that the item was medically necessary. The Plan denied your 
request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain sufficient medical records which support medical necessity for the supplies 
provided in this case. Specifically, the records do not show a face to face visit with the ordering physician ever 
occurred. The plan documentation indicates that the enrollee received an unsolicited offer for the DME at issue.  
Therefore, we decided that the Plan does not have to pay for a brace (L0457) provided August 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Fentanyl.  
 
Benefits for these services 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 pre-approve herbal products. 
 
You asked the Plan to pre-approve the herbal products. You say that you have chemical sensitivities and 
require these products. The Plan denied your request. The Plan says the requested items are not covered under 
the OTC benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  
The contract with the Plan says that OTC benefits are limited to ?Drug Store? type items using an account that 
is replenished with funds monthly. The following product categories are offered: medicines, ointments and 
sprays with active medical ingredients, first aid supplies, incontinence supplies, vitamins and minerals, 
diagnostic equipment, and more. The items covered by the benefit are limited to items that are consistent with 
CMS guidance. 
 
The items you asked the Plan to pre-approve are herbal products, which are not covered under the Plan?s OTC 
benefit. Therefore, we decided that the Plan does not have to pre-approve the herbal products.