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

 
We decided that the Plan does not have to pay for the medical services provided on April 23, 2020 by a non-
network provider. 
 
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 were rendered by a non-network provider without prior authorization. 
 
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 referring provider 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 April 23, 2020 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can safely receive needed care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving and only requires short term additional acute care hospital services which can be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services you received. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for the services listed above.  
 
We looked at the file and Medicare rules. The requested air ambulance services do not meet the above criteria 
for coverage of care provided outside the Unites States. Additionally, the air ambulance services do not fall 
within the emergency ambulance category. 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 pay for the air 
ambulance services you received.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 7, 
2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual 
policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle 
electromyography services coded 95886, the unlisted neurological or neuromuscular diagnostic procedure 
coded 95999, and the electroencephalogram (EEG) during non-intracranial surgery services coded 95955 
provided on April 9, 2020. 
 
You asked the Plan to pay for the nerve conduction studies, the needle electromyography services, the unlisted 
neurological or neuromuscular diagnostic procedure, and the electroencephalogram (EEG) during non-
intracranial surgery services. You say that you would like the plan to reconsider their denial. The Plan denied 
your request. The Plan says the services billed are not supported by the documentation. 
 
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 95908, 95886, 95999, and 95955 are not supported in the medical record. Specifically, 
the technical report did not include documentation of nerve conduction studies, for 3-4 studies; therefore, code 
95908 cannot be verified. The technical report did not include documentation of a complete needle 
electromyography, per each extremity with related paraspinal areas when performed, done with nerve 
conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or 
more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); 
therefore, code 95886 cannot be verified.  The technical report did not include documentation of an 
electroencephalogram (EEG) during a non-intracranial surgery (e.g., carotid surgery); therefore, code 95955 
cannot be verified. The documentation does not support that unlisted neurological or neuromuscular diagnostic 
procedure were provided; therefore, code 95999 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies, the 
needle electromyography services, the unlisted neurological or neuromuscular diagnostic procedure, and the 
electroencephalogram (EEG) during non-intracranial surgery services have not been met. Therefore, we 
decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle 
electromyography services coded 95886, the unlisted neurological or neuromuscular diagnostic procedure 
coded 95999, and the electroencephalogram (EEG) during non-intracranial surgery services coded 95955 
provided on April 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the excision of a lesion of tendon sheath 
provided on August 7, 2020. 
 
You asked the Plan to waive the copayment for the excision of a lesion of tendon sheath. You say that you 
were told that you would only owe a $150 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.  
 
You have been asked to pay a $250 copayment for the excision of a lesion of tendon sheath. The excision of a 
lesion of tendon sheath falls within the outpatient surgery 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 excision of a lesion of tendon sheath provided on August 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine-Prilocaine cream (J3490). 
 
You asked the Plan to pre-approve Lidocaine-Prilocaine cream. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Lidocaine-Prilocaine cream 
(J3490).  
 
Benefits for Lidocaine-Prilocaine cream 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation and sclerotherapy. 
 
You asked the Plan to pre-approve the vein treatment. You say that you are requesting this approval to remove 
the 90 day wait period. Please expedite the procedure that could help to reduce her pain and greatly increase 
her quality of life. The Plan denied your request. The Plan says the records do not show that you have tried 
other types of conservative treatments for 3 months. 
 
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. Medicare rules require that you have a three-month trial of 
conservative treatment of your condition to see if the conservative treatment helps you before we are able to 
consider the requested invasive procedure. Conservative treatment includes: exercise, periodic leg elevation, 
weight loss, compliance with wearing compression stockings for three months to see if these things help your 
condition. The information provided does not show this information. Based on this information, we decided 
 
 
that Medicare rules for coverage of the vein treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation and sclerotherapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on December 13, 2019. 
 
You asked the Plan to pay for lab tests. You say that this lab testing was part of your annual examination to 
follow-up on your health problems, and you feel you should not be penalized for this. The Plan denied your 
request. The Plan says that the denial of payment for these services is correct, because this testing is not 
covered. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will  not be 
covered. 
 
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 did not specify whether the ordering physician for this testing was in-
network or out-of-network with the Plan. The documentation submitted does not include prior notice from the 
Plan that this testing would not be covered. Without this information, we cannot determine whether the lab 
order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment 
for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for 
laboratory testing provided on December 13, 2019.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee. 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested device does not meet 
the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that an ultrasonic osteogenesis stimulator is covered if the 
above criteria have been met. 
 
In this case, the file does not show that there were 2 or more serial radiographs separated by 90 or more days 
confirming that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis 
stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on June 
10, 2020. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you have never paid for 
a pacemaker check before. You say that you were unaware you had to pay an additional $20. The Plan denied 
your request. The Plan says the copayment 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 $20 
copayment per visit to a specialist.  
 
You have been asked to pay a $20 copayment for the pacemaker evaluation. The pacemaker evaluation falls 
within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the pacemaker evaluation provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on July 15, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that the injection 
was necessary but you cannot afford the charges. 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 injection on July 15, 2020. The allowed amount is $1,056 and 20% of 
that is $211.20.  
 
You have been asked to pay the total coinsurance amount of $211.20 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a Medicare Part B drug injection provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture service provided on August 28, 2020. 
 
You asked the Plan to pay for acupuncture. You say that you were informed that this service was covered. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
acupuncture was not performed for a Medicare-covered indication and the rendering provider is not a physician 
or under the supervision of a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, these services were not provided for chronic lower 
back pain. Additionally, the rendering provider is not a physician and therefore does not meet the Plans criteria 
for coverage beyond Medicare coverage. Therefore, we decided that the Plan does not have to pay for 
acupuncture service provided on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Superion interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. Your 
confusion and performance status will not allow you to receive 15 hours per week of therapy. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99336) provided on June 1, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 service 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 physician services (99336) provided on June 1, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health visits for medication administration. 
 
You asked the Plan to pre-approve this service under the Medicare benefit. You say that you need someone to 
come to your home and help you with a traditionally self-administered shot. The Plan denied your request. The 
Plan says this is not a service for which home health visits are approved under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. You are asking for assistance to administer a 
self-administered medication. This does not require skilled nursing services. This type of assistance is not 
covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve home health visits for 
medication administration under the Medicare benefit.