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

We decided that the Plan does not have to pre-approve PET scan with concurrently acquired CT scan for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says repeat scans are not supported for treatment planning. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has a stable 
8-9mm right upper lobe nodule with no change between 2 CT scans of 2/12/28 and 7/2/19 and importantly a 
negative PET/CT on 9/11/18. CMS CMS allows for the characterization of one pulmonary nodule via PET 
imaging when there is a suspicion of possible cancer. Equally importantly the records do not show a followup 
CT of the chest since 7/2/19. If an interval increase in size of the nodule was noted between the prior CT of 
7/2/19 and a more current scan of 2020 a repeat PET scan would be in the best interests for the patient as 
biopsy would be hazardous given the history of COPD. In the absence of an interim CT of the chest since 
7/2/19 the medical necessity of repeat PET/CT has not been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan with concurrently acquired CT scan for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 8, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a steroid injection (20610) received on June 
8, 2020. 
 
You asked the Plan to waive the copayment for a steroid injection. You say that you should not be charged for 
surgery when you did not have any surgery. 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 $100 
copayment for Medicare-covered surgery.  
 
You have been asked to pay a $100 copayment for a steroid injection. A steroid injection falls within the 
"Outpatient Surgery and Other Medical 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 steroid injection 
(20610) received on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cone beam (D0367) and implant removal (D6100). 
 
You asked the Plan to pre-approve dental codes D0367 and D6100. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered by Medicare 
or the 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, the requested dental codes D0367 and 
D6100 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve cone beam (D0367) and implant removal (D6100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the services. You say that the current dentures no longer fit after radiation 
treatment altered the enrollee's mouth. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office or other outpatient visit (99203) 
provided on June 3, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient visit. You say that this service was 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 new patient office or other outpatient visit 
(99203) provided on June 3, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pacemaker insertion procedure you 
had at an out-of-network outpatient hospital facility from December 18, 2019, to December 19, 2019. 
 
You asked the Plan to waive the coinsurance for the out-of-network outpatient hospital services. You say that 
you were so sick that you never thought about making sure this hospital was in-network. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 30% 
coinsurance for surgery or other services at an out-of-network outpatient hospital facility.  
 
You have been asked to pay 30% coinsurance for the out-of-network outpatient hospital 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. Your contract clearly states that if you 
use out-of-network providers, your costs may be higher. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the pacemaker insertion procedure you had at an out-of-network outpatient hospital 
facility from December 18, 2019, to December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit and diagnostic imaging of 
retina (99213, 92134) provided on August 3, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for office or other outpatient visit and diagnostic imaging of retina. You say that you 
did not realize the provider was not in-network. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 office or other outpatient visit and diagnostic 
imaging of retina (99213, 92134) provided on August 3, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the legs (93925) 
performed on February 26, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the legs. You say that this procedure is done 
every year as a preventive and that preventive procedures are supposed to be covered. 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 $155 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays. The contract does 
not label such services as preventive. 
 
You have been asked to pay a $155 copayment for an ultrasound of legs. An ultrasound of legs 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 of the legs (93925) performed on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hoyer lift (E0635). 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the enrollee is bed bound. 
 
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 lift. Our reviewer says that the 
requested lift is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there is no documentation that transfer between the bed and a chair/wheelchair/commode is required. There is 
no documentation that without this lift the enrollee would be bed-confined. 
 
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 lift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Hoyer lift (E0635).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 spacer. Our reviewer says that the 
requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy of the device. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) on June 29, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were referred to this 
doctor for the visit. 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 consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit 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 a specialist office visit (99214) on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breast Cancer Index testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show negative lymph node disease. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case the documentation indicates that you have breast cancer staging listed as T3N1M0. 
Additionally, BCI is tested once per patient lifetime on FFPE tissue from the primary tumor specimen obtained 
prior to adjuvant 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Breast Cancer Index testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 heavy duty power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says [the submitted documentation does not establish the medical necessity for this 
request. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found a medical 
note dated 06/04/2020 states that she would benefit from a cane and rollator and a note dated 07/13/2020 states 
she walks 50 feet with a cane. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 1 heavy duty power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and custom-fabricated abutment (D6075 and 
D6059) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 pre-approve a 
crown and custom-fabricated abutment (D6075 and D6059) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on July 15, 
2020. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that no prescription for medication 
or test was prescribed. You say that you don't agree with $30 for a 5-minute phone call. 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 $30 
copayment for each Medicare covered specialist visit.  
 
You have been asked to pay a $30 copayment for the telehealth visit. The telehealth visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the 
telephone visit was with a specialist. 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 telehealth visit 
provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic socket liner (L5679 x1). 
 
You asked the Plan to pre-approve the liner. You say that you need 3 liners because you wear through them 
quickly because of your activity level. The Plan denied your request. The Plan says no more than 2 liners can 
be covered at a time. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two of the same socket inserts are 
allowed per prosthesis at the same time. . 
 
We looked at the file and Medicare rules. The plan has approved two liners already. Three liners exceed the 
number allowed. Based on this information, we decided that Medicare rules for coverage of the liner have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic socket liner (L5679 
x1).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a follow-up CT scan is not medically necessary until twelve months later. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found per the Fleischner Society 
2020 guidelines multiple nodules measuring less than 6 mm in diameter in a high risk patient such as this 
individual may be considered for a one year CT follow-up. The guidelines do not support CT surveillance 
sooner than 1 year for nodules less than 6 mm even in high risk patients such as this individual. Thus the 
requested CT scan should not be approved sooner than a 1 year follow-up from the prior CT of 2/21/20. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the chest for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla Tab. 
 
You asked the Plan to pre-approve Otezla Tab. You say that this drug helps your medical condition and your 
do not want the alternative of injections. The Plan denied your request. The Plan says this drug is not covered 
under your Medicare Part B benefit. 
 
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 Otezla Tab.  
 
Benefits for Otezla Tab may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.