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

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is covered for enrollees in a clinical study. 
 
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 surgery. Our reviewer says that the 
requested surgery not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is considered experimental. More research is needed to show safety and efficacy. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided lumbar decompression.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral transforaminal epidural. 
 
You asked the Plan to pre-approve lumbar/sacral transforaminal epidural. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered for 
certain 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 lumbar/sacral transforaminal epidural. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has lumbosacral spinal stenosis, lumbosacral facet 
joint syndrome and spondylolisthesis of lumbosacral region. The documentation shows that the enrollee has 
"strong neurogenic claudication symptoms consistent with severe spinal stenosis at multiple levels." The 
documentation shows that on May 8, 2020 the enrollee received 18 mg betamethasone acetate for the prior 
steroid injection, which is greater than the CMS allowable amount of 12 mg of betamethasone. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar/sacral transforaminal epidural have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar/sacral transforaminal epidural.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says no documentation was provided to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
the plan to support medical necessity. The plan requested medical records various times with no response. 
Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CT scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve facet joint injection. You say that the records support the need for this 
procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the enrollee does not meet the Medicare criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered when the 
enrollee meets all of the clinical criteria listed 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 facet joint injection. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injection. Our physician 
reviewer found in this case, the enrollee's pain severity was noted as 3/10 and no other pain scores are 
documented. The records do not show that the enrollee has satisfied all the criteria for coverage of the 
requested facet joint injection. Therefore, this procedure 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 facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays provided on March 4, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the x-rays were needed. You say that if you 
knew they wouldn't be covered you would have changed the appointment. The Plan denied your request. The 
Plan says bitewing x-rays are only allowed every 12 months. 
 
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 Plan also has a maximum benefit 
of one set of bitewing x-rays every 12 months. The Plan paid for bitewing x-rays you received on March 6, 
2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the bitewing 
x-rays provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy provided on April 27, 2020 by 
an OON provider. 
 
You asked the Plan to pay more for the endodontic therapy. You say that due to COVID-19 you did not have 
much of a choice of where to go for services. The Plan denied your request. The Plan says this claim was 
processed, and you were paid the allowable percentage. 
 
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 Plan is only obligated to pay 45% 
of the allowed amount for your covered dental services from an OON provider. The records show that this 
claim was processed correctly. Therefore, we decided that the Plan does not have to pay more for the 
endodontic therapy provided on April 27, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 18, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 6, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges 
because you were told that since the services were provided during a preventative visit you would not be 
charged. 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 $100 
copayment for ultrasounds.  
 
You have been asked to pay the allowed amount of $93.54, which is less than the $100 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on March 
6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair transportation (A0130) provided January 27, 
2020 
 
You asked the Plan to pay for the wheelchair transportation. You say that the case manager had set up the 
transport. You were advised that you would have to pay for it and then ask for reimbursement. The Plan denied 
your request. The Plan says there was no prior authorization for this transport. The transporting provider is out 
of network and the total miles of 341 miles exceeds the mileage benefit limit of 60 miles. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers routine transportation when Transportation arranged outside of the transportation vendor 
will not be covered and will be the responsibility of the member. A maximum trip distance of 60 miles per one-
way trip applies. Prior Authorization is required where the travel distance to a provider exceeds the mileage 
limit of 60 miles. Trip distances exceeding 60 miles per one-way trip are not covered except when 
transportation is needed to obtain specific medically necessary Medicare or Plan covered services.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for the wheelchair transportation (A0130) provided January 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radioembolization procedure (77499). 
 
You asked the Plan to pre-approve a radioembolization procedure. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental for the enrollee's condition. 
 
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 radioembolization procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the compendia support consideration of radioembolization for patients with 
preserved liver function and no extrahpatic tumor spread, vascular invasion, or tumor thrombus. Review of the 
documentation does not support these criteria have been met. The literature does not provide support for the 
procedure for individuals with disease burden equivalent to the enrollee's. 
 
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 radioembolization procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a radioembolization procedure (77499).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on February 25, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went for your wellness exam. 
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 $20 
copayment for physician/practitioner services/primary care visit.  
 
You have been asked to pay a $20 copayment for an office visit. When services are provided that go beyond an 
annual wellness exam then additional copayments are applied; therefore, the correct copayment has been 
applied. An office visit falls within the physician/practitioner services/primary care visit 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 office visit provided by a participating provider on 
February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Perfect Sleep Chair Duralux Leather (E1399) DME delivery, 
set up  and/or dispensing service (A9901) and sales tax (S9999) provided November 20, 2019. 
 
You asked the Plan to pay for the seat lift mechanism, delivery and set up and sales tax.. You say that you have 
enclosed a signed note from your doctor saying it is medically necessary for you to have a lifting chair. The 
chair has been a tremendous help for you. The Plan denied your request. The Plan says the records provided do 
not support medical necessity. A9901 and S9999 are excluded from coverage and not payable. 
 
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. The records show that the plan requested medical records from your 
doctor multiple time. The medical records were not received. Based on this information, we decided that 
Medicare rules for coverage of the seat lift mechanism, delivery and set up and sales tax. have not been met. 
Therefore, we decided that the Plan does not have to pay for Perfect Sleep Chair Duralux Leather (E1399) 
DME delivery, set up  and/or dispensing service (A9901) and sales tax (S9999) provided November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 medical 
services to be provided by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided 
November 14, 2019 to December 30, 2019. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Substance abuse facilities are not eligible for 
Medicare participation and therefore cannot receive payment.  
 
We looked at the file and Medicare rules. The provider does not participate in the Medicare program. Based on 
this information, we decided that Medicare rules for coverage of the outpatient mental health services have not 
been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
(90834) provided November 14, 2019 to December 30, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 17, 
2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges 
because you were told that you would not owe a copayment. You state that you told them that a polyp was 
being removed and they did not say you had a copayment. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You state that a polyp was removed during a colonoscopy on March 17, 2020. Therefore, the colonoscopy is 
considered diagnostic, not preventative, and you are responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the echocardiogram provided on October 
4, 2019. 
 
You asked the Plan to reduce the copayment for the echocardiogram. You say that you were told you would 
only have a $25 copayment. 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 $225 
copayment for Medicare-covered diagnostic radiological services (such as CT scans and MRIs).  
 
You have been asked to pay a $225 copayment for the echocardiogram. The echocardiogram falls within the 
Medicare-?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 reduce the copayment for the echocardiogram provided on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
March 5, 2019 to July 23, 2019. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
charges because you were not aware that you would owe such a large amount. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on March 5, 2019. The allowed amount is $2,863.80 and 20% of that is 
$572.76.  
 
You received a Medicare Part B drug on April 2, 2019. The allowed amount is $3,260.28 and 20% of that is 
$652.06. 
 
You received a Medicare Part B drug on May 28, 2019. The allowed amount is $2,716.90 and 20% of that is 
$543.38. 
 
You received a Medicare Part B drug on July 23, 2019. The allowed amount is $2,566.20 and 20% of that is 
$513.24. 
 
The total amount you owe is: $2,281.44.  
 
You have been asked to pay the total coinsurance amount of $2,281.44 for Medicare Part B drugs. Medicare 
Part B drugs fall 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for Medicare Part B drugs provided from March 5, 2019 to July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 24, 
2020 to January 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. 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 $300 
copayment for Inpatient Care.  
 
You have been asked to pay a $300 copayment for the inpatient hospital care. The inpatient hospital care falls 
within the Inpatient 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 inpatient 
hospital care provided January 24, 2020 to January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on April 9, 2019, July 11, 
2019 and January 14, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that you assumed you were covered for 
reimbursement up to $150. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 
periodontal maintenance provided on April 9, 2019, July 11, 2019 and January 14, 2020.