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

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, lumbar; without 
contrast material (72148), for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee complains of numbness, pins and 
needles sensation in their feet. The Plan denied your request. The Plan says the Medicare rules have not been 
met. 
 
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 physician reviewer found 
based on the provided documentation, the diagnosis appears to be diabetic neuropathy and not likely to have a 
lumbar radiculopathy component. Also, there was no reported trial and failure of conservative treatments to 
justify MRI. Therefore, this request for lumbar MRI will be considered 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, lumbar; without contrast material (72148), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cooled radiofrequency ablation (cooled RFA) 
procedure. 
 
You asked the Plan to pre-approve cooled RFA. You say that the enrollee has failed medical management, 
rehabilitative treatment, and is not a surgical candidate. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that non-thermal radiofrequency ablation methods are 
excluded from coverage at this time. 
 
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 cooled RFA. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested cooled RFA. Our physician reviewer found the 
enrollee is an excellent candidate for traditional radiofrequency ablation, however Medicare has specifically 
stated that cooled and pulsed RFA are not acceptable. Since cooled RFA has been requested, the request is 
considered 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 cooled RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cooled radiofrequency ablation (cooled RFA) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the maxillary complete denture. You say that you would like the 
authorization for the denture appealed. The Plan denied your request. The Plan says this service is not covered 
under your 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 
maxillary complete denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic care provided to the enrollee 
from August 12, 2019 to August 21, 2019. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the 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 out of network chiropractic care provided to the enrollee from August 12, 2019 to 
August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venipuncture to be provided at home. 
 
You asked the Plan to pre-approve the venipuncture. You say that the member needs to continue with their at 
home blood tests as they are unable to walk or see due to their condition. The Plan denied your request. The 
Plan says the records do not show that the member needs any skilled services. 
 
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 venipuncture. Our reviewer says 
that there is no evidence that the enrollee is in need of skilled nursing care or skilled rehabilitative services. Our 
physician reviewer found venipuncture is not in-and-of itself an indication for skilled nursing 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 the venipuncture have not been met. Therefore, we decided that the Plan does 
not have to pre-approve venipuncture to be provided at home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that this 
device would restore function to the dysfunctional arm and the ability to perform activities of daily living. The 
Plan denied your request. The Plan says a review of the current medical literature indicates that this device is 
considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary, and are experimental and investigational, are not covered.   
 
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show 
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by 
Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its 
effectiveness. Based on this information, we decided that Medicare rules for coverage of a powered upper 
extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered upper extremity range of motion assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral liquid nutrition. 
 
You asked the Plan to pre-approve oral liquid nutrition. You say that you need oral liquid nutrition to gain 
weight for a future surgery. The Plan denied your request. The Plan says enteral nutrition for oral intake is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
Medicare rules say that enteral nutrition products administered orally are not covered.  
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve oral liquid nutrition.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the PET imaging would be diagnostically 
informative. The Plan denied your request. The Plan says the testing is only covered after other testing has been 
complete and a diagnosis is unable to be confirmed. 
 
The Plan follows Medicare rules. Medicare rules say that PET scans are only covered under certain medical 
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 a PET scan. Our physician reviewer 
found that the enrollee has a history of memory problems. He recently underwent neuropsychological 
evaluation, in which it was indicated that while his test profile does not present a clear diagnostic picture, the 
most likely underlying etiology is a combination of Alzheimer's disease (AD) and cerebrovascular disease. 
Medicare rules say that a PET/CT scan (of the brain) may be covered for dementia when an enrollee meets the 
diagnostic criteria for both AD and FTD. In this case, the records provided do not support that this requirement 
for coverage of a PET/CT scan has been met. While the notes suggest a suspicion of AD, there was no 
suspicion of FTD noted. Nor does the member meet diagnostic criteria for FTD. Therefore, the requested 
testing is not considered 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided on
August 7, 2019 performed at the outpatient department.
You asked the Plan to waive the copayment for diagnostic radiology services. You say that you are appealing
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received diagnostic radiology services provided on August 7, 2019 performed
at the outpatient department. You are asked to pay a $175 copayment for the radiology services. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for diagnostic radiology services provided on August 7, 2019 performed
at the outpatient department.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that you need a power wheelchair. 
The Plan denied your request. The Plan says the information provided does not report if your mobility issue can 
be resolved by a wheelchair, cane, or walker or if your home has adequate space to use a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair, or you can safely operate the PMD 
being requested. There is no Face-to-Face, Home Assessment, or Specialty Evaluation documentation. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI guided high intensity focused ultrasound (MRgFUS), 
stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame 
placement when performed. (0398T) 
 
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that Medicare considers this procedure unreasonable and not 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 physician reviewer found 
the patient is not a candidate for deep brain stimulation and has no contraindications for this procedure based 
on the documentation provided. In the case of this patient, after review of the provided documentation, the 
evidence supports a trial of this procedure. Therefore, the patient meets the requirements listed in the LCD for 
Medicare coverage for MRI guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, 
intracranial for movement disorder including stereotactic navigation and frame placement when performed. 
(0398T). 
 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
MRI guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for 
movement disorder including stereotactic navigation and frame placement when performed. (0398T)  
 
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 waive the copayments for the lab services you received on August 8, 
2019, and August 30, 2019. 
 
You asked the Plan to waive the copayments. You say that you already paid a copayment. The Plan denied 
your request. The Plan says you are responsible for the cost share. 
 
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 $15 
copayment for lab services.  
 
Review of the file shows that you were provided lab services on August 8, 2019, and August 30, 2019. Per the 
Plan contract, there is a $15 copayment for lab services. The Medicare allowed amounts for the lab services in 
question were $5.69 and $9.40, respectively. Since each allowed amount is less than the required copayment, 
you have been asked to pay the lesser amount. 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 copayments for the lab 
services you received on August 8, 2019, and August 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy visits. 
 
You asked the Plan to pre-approve 16 additional physical therapy visits. You say that the clinicals with updated 
progress note should be reviewed. You say that you are looking for 16 additional visits. The Plan denied your 
request. The Plan says additional visits 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 16 additional physical therapy visits. 
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 says that the unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 16 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 27, 2020.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says you have already received the maximum amount of
coverage allowed for this type of service.
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.
You exhausted your $1,000 maximum benefit allowance. Your EOC states, " non-Medicare covered dental
services allowance: $1,000 every year for Non-Medicare covered preventive dental services and Non-Medicare
covered comprehensive dental services combined. You are responsible for any amount above the dental
coverage limit." Therefore, we decided that the Plan does not have to pay for the dental services provided on
February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the occupational therapy visit provided on 
June 16, 2020. 
 
You asked the Plan to waive the copayment for the occupational therapy visit. You say that you did not receive 
any therapy. 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 $35 
copayment for each therapy visit. 
 
You have been asked to pay a $35 copayment for the occupational therapy visit. The occupational therapy visit 
falls within the ?Outpatient rehabilitation services? benefit category. The medical record shows you were seen 
for an initial evaluation for an orthosis assessment. 
 
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 occupational therapy visit provided on June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 31, 
2019 through January 9, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were only in the 
facility for a few hours prior to the start of the year 2020 and the cost-share should be applied to the benefit 
year of 2020 instead. The Plan denied your request. The Plan says the claim was processed accordingly with 
your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on December 31, 2019 and discharged on January 9, 2020. 
You were asked to pay a $250 copayment per day from December 31, 2019 through January 6, 2020, days 1-7 
of your inpatient stay. There were no copayment charges from January 7, 2020, day 8 of your inpatient hospital 
care until your day of discharge January 9, 2020. Per your contract there is a $250 copayment per day required 
for days 1-7. 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 from December 31, 
2019 through January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating 
provider on January 30, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you do not agree with the 
coinsurance amount applied. The Plan denied your request. The Plan says the correct coinsurance 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% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total allowed 
amount is $7,298.75. The total amount you are being asked to pay is $1,459.76 ($7,298.75 x 20% = $1,459.75). 
Chemotherapy 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 chemotherapy provided by a participating provider on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 20, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says pass-through billing is not permitted. 
 
The Plan must follow Medicare rules. Medicare rules say that pass-through billing is not permitted.  
 
It does not appear as if the billing provider rendered these services. 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 laboratory services provided to the enrollee on February 20, 2020.