Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered for the above indications. 
 
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 RFA. Our reviewer says that the 
requested RFA is medically reasonable and necessary in this case. Our physician reviewer found that this 76-
year-old woman has chronic Right sided neck pain. She has tried and failed Gabapentin and Lyrica. She 
underwent dual diagnostic cervical facet blocks and achieved greater than 90% pain relief, that lasted the 
duration of the local anesthetic. The request meets the criteria of the LCD and is medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the RFA have been met. Therefore, we decided that the Plan has to pre-approve 
radiofrequency ablation (RFA).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a medial branch block to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria has not been met. 
 
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 medial branch block to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services 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 the records do not show that the enrollee and/or the caregiver cannot take care of needs 
at home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary.  
 
 
 
 
The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's 
condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular risk panel (81401, 81403, 81404, 81405, 
81406, 81407, 81408, 81410, 81479) provided. 
 
You asked the Plan to pay for the cardiovascular risk panel. You say that the testing was medically necessary. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
risk assessment panels, except the basic lipid panel.  
 
We looked at the file and Medicare rules. The cardiovascular risk assessment panel performed is not a covered 
service. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk 
panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular risk 
panel (81401, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81479) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 3, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not know this service 
would not be covered when you switched dentists. You also say that you did not know it was your 
responsibility to check if a service is covered or not. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on June 20, 2019, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit and lesion destruction 
provided on April 16, 2020. 
 
You asked the Plan to waive the deductible for the office visit and lesion destruction. You say that you went in 
April as requested instead of June. You say that had your deductible would have been paid had your 
appointment been scheduled for June. The Plan denied your request. The Plan says the deductible applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your combined in-network and out-of-network medical deductible is $250. This 
is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. 
Until you have paid the deductible amount, you must pay the full cost for most of your covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner 
Services, Including Doctor?s Office Visits" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $250 deductible applies physician services. This cost sharing is a 
contractual obligation that had not been met at the time the office visit and lesion destruction was received on 
April 16, 2020. Please contact the Plan for information regarding what cost share can be waived. Therefore, we 
decided that the Plan does not have to waive the deductible for the office visit and lesion destruction provided 
on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear you received on June 4, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has 
been paid. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 every year. 
 
 
 
We looked at the file and the Plan's rules. The records show that the Plan has paid $200 toward the eyewear in 
question. You are responsible for any amount over the $200 benefit limit. Based on this information, we 
decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay for the eyewear you received on June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84443, 36415, 80061, and 80053) 
provided on May 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by 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 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 laboratory services (84443, 36415, 80061, and 
80053) provided on May 29, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is needed to help with managing the enrollee's 
severe pain. The Plan denied your request. The Plan says four to six weeks of conservative therapy is 
recommended. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the available clinical 
documentation does not support that the enrollee has cervical spine pain that has not responded to appropriate 
medical therapy. Consequently, an MRI of the cervical spine is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the cervical spine.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
28, 2020 to June 30, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the claim was submitted with an invalid type of 
bill code. 
 
 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim was billed with an inappropriate type of bill code. Additionally, per the Physician Fee 
Schedule, CPT code S9123 has a status indicator of I and is not valid for Medicare purposes. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from June 28, 
2020 to June 30, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the therapy services you received on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the allowed 
amount has been reached for therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the allowed amount was reached for therapy services. 
However, the Plan has not provided documentation supporting this. The documentation submitted does not 
show that therapy benefit limit exists, nor that a benefit limit has been reached. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
therapy services you received on January 21, 2020.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient observation care provided on 
May 2, 2020 through May 3, 2020. 
 
You asked the Plan to waive the copayment for outpatient observation care. You say that you do not believe 
you should be responsible for copay. The Plan denied your request. The Plan says the cost share is correct. 
 
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 $100 
copay for outpatient hospital observation.  
 
You have been asked to pay a $100 copay for outpatient observation care. This service falls within the 
outpatient hospital observation 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 
outpatient observation care provided on May 2, 2020 through May 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance angiography of 
neck blood vessels and magnetic resonance imaging of brain provided on June 26, 2020. 
 
You asked the Plan to waive the copayment for the magnetic resonance angiography of neck blood vessels and 
magnetic resonance imaging of brain. You say that you should be charged a coinsurance of 20%. The Plan 
denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $150 
copayment for Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $150 copayment for the magnetic resonance angiography of neck blood vessels 
and a $150 copayment for the magnetic resonance imaging of brain for a total cost share of $300. Both the 
services provided fall within the Medicare-covered radiological diagnostic service, not including X-rays 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 magnetic resonance angiography of neck 
blood vessels and magnetic resonance imaging of brain provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided from July 
6, 2020 to July 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
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 inpatient psychiatric hospital services provided 
from July 6, 2020 to July 11, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy services rendered on May 15, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount for therapy was reached. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered on May 15, 2020.  
 
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 drug tests (80307, G0482) provided on April 20, 2020. 
 
You asked the Plan to pay for drug tests. You say that these tests were medically necessary. The Plan denied 
your request. The Plan says these tests were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, these services 
were billed for a date of service of April 20, 2020, but the record shows that the specimens tested were not 
received until April 21, 2020. Based on this information, we decided that Medicare rules for coverage of drug 
tests have not been met. Therefore, we decided that the Plan does not have to pay for drug tests (80307, G0482) 
provided on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite on a posterior tooth provided on 
July 29, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that according to the Plan's 2020 EOC, minor 
restorative services including fillings and crown repair are covered with no copay. You also say that it is not 
specified which type of fillings are covered. The Plan denied your request. The Plan says you received the 
correct coverage for the resin-based composite filling. The Plan also says that only the amount that the Plan 
would have paid to restore the tooth with amalgam will be covered. 
 
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, you are responsible for the difference 
in cost between the resin-based composite and the amalgam. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite on a posterior tooth provided on July 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services received on 
August 26, 2020. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you would never have 
gone to physical therapy if you had known there was a charge to you. The Plan denied your request. The Plan 
says the correct copayment was 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 $35 
copayment for each Medicare-covered therapy visit.  
 
You have been asked to pay a $35 copayment for physical therapy services. Physical therapy services fall 
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 services received on August 26, 2020.