Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly AM OR Affinity skin substitute graft. 
 
You asked the Plan to pre-approve the skin substitute. You say that you would like reconsideration because 
these supplies are medically necessary. The Plan denied your request. The Plan says the member does not meet 
Plan coverage criteria. 
 
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 skin substitute. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no indication of appropriate circulation in the affected wound area. The 
records provided state that the member's extremities are cool and pulses are unable to be felt by touch. 
 
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 skin substitute have not been met. Therefore, we decided that the Plan does 
not have to pre-approve PuraPly AM OR Affinity skin substitute graft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from 
December 3, 2019 through December 5, 2019. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
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 pay for post-stabilization care. Our physician 
reviewer found the post-stabilization care services after 3:46 p.m. on December 3, 2019 were not medically 
necessary and reasonable. The review has determined that the treating physician did not document (in the 
physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from December 3, 2019 through 
December 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy and Image Transformation Therapy to be
rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that the requested treatment with the out of network
provider is medically necessary. The Plan denied your request. The Plan says it is not medically reasonable or
necessary to refer you to a non-Plan provider for treatment when services are available from a network
provider. The Image Transformation therapy requested is not a Medicare covered service.
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 provider at issue in this case is not a network provider with the Plan. 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 these services. Our reviewer says that you do not meet criteria for coverage
of psychotherapy and Image Transformation therapy with the out of network provider. Our physician reviewer
found that you do not require treatment by an out-of-network provider as the medical plan is able to provide a
psychotherapist for the treatment of your condition. You do not meet the condition of being in an
urgent/emergent condition as the in network provider is credentialed and maintained by the medical provider to
a certain standard of care. You can safely be transitioned to an in-network therapist offered by your plan who is
credentialed and certified by your medical plan. Additionally, the use of image transformation therapy (ImTT)
is not considered medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met.
The Plan has network providers available who can provide the psychotherapy services at issue in this appeal.
The Image Transformation Therapy is not medically necessary. 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
psychotherapy and Image Transformation Therapy to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the consultation (D9310). 
 
You asked the Plan to reimburse you for the consultation (D9310). You say that the dentist refused to do a root 
canal. You say that you want your copayment refunded. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a $35 
copayment for the consultation. Therefore, we decided that the Plan does not have to reimburse you for the 
consultation (D9310).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drugs provided on February 19, 2020. 
 
You asked the Plan to waive the coinsurance for the drugs provided while outpatient. You say that you were 
told the procedure was covered. The Plan denied your request. The Plan says the drugs are covered with a 20% 
coinsurance. 
 
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 have been asked to pay 20% coinsurance for the drugs provided while outpatient. The drugs provided 
while outpatient 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 the drugs provided on February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of breast implants. 
 
You asked the Plan to pre-approve the breast implant removal. You say that you would like reconsideration 
because you are experiencing side effects from your implants. The Plan denied your request. The Plan says you 
do not have any of the qualifying covered conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast implant removal. Our 
reviewer says that you do not meet LCD criteria for the removal of breast implants. The record does not show 
that you have a broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference 
with diagnosis of breast cancer or painful capsular contracture with disfigurement. Our reviewer found the 
plastic surgeon documents that your symptoms may not be fully explained by your implants. 
 
 
 
 
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 breast implant removal have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the removal of breast implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical doesn't indicate the enrollee checks glucose levels four or more times per 
day. 
 
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 services. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have not been using insulin multiple (3 or more) times per day. There is a specific stated plan that 
glycemic control is currently inadequate given his anticipated cardiac transplant on current twice daily insulin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on February 4, 2020 from a non-
participating hearing vendor. 
 
You asked the Plan to pay for the hearing aids. You say that you were not made aware of the change for 
hearing aids. The Plan denied your request. The Plan says the provider is not in the vendor network. The Plan 
states you were mailed an Annual Notice of change on December 2, 2019 and the notice shows the change in 
hearing aids benefits. 
 
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. 
 
Review of the file show that you purchased hearing aids on February 4, 2020 from a provider tht is not in the 
vendor network. Your EOC states, "hearing aids ordered through providers other than the Plan Hearing are not 
covered." 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 hearing aids purchased on February 4, 2020 from a non-participating 
hearing vendor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on March 9, 2020. 
 
You asked the Plan to pay for the physician's services. You say that you were referred to this provider by your 
doctor and at no time were you told this physician was not an in-network provider. The Plan denied your 
request. The Plan says that you must receive care from in-network providers with the exception of emergency 
or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an 
in-network provider, which requires prior authorization from the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say a contract plan provider is an agent of the plan. Services and referrals obtained from a 
plan provider are viewed as plan-approved unless notice is given 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 has not provided us with information with regard to the network status 
of the referring provider. Therefore, we decided that the Plan has to pay for the physician's services provided 
on March 9, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for under Nerve Conduction Tests - 95912-26 and Needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction 
(95886-26) needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with 
nerve conduction (95886-26) unlisted neurological or neuromuscular diagnostic procedure (95999) provided 
November 22, 2019. 
 
You asked the Plan to pay for the nerve conduction tests. You say that please review enclosed documentation 
and remit payment accordingly. The Plan denied your request. The Plan says the records do not support the 
billed service. The required primary service code was not supported and the add-on codes cannot be reimbursed 
separately. There is a more appropriate HCPCS code for the procedure performed. 
 
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 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 pay for the nerve conduction tests. Our reviewer 
says that the medical records do not support the service. Our physician reviewer found the enrollee underwent 
neuromonitoring during a posterior spinal fusion surgery, with hardware removal. There is description of a 
negative neurophysiologic intraoperative study, documenting no significant events, changes or data. The 
documentation is insufficient in regard to nerve conduction studies; 11 - 12 studies. 
 
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 nerve conduction tests have not been met. Therefore, we decided that the 
Plan does not have to pay for under Nerve Conduction Tests - 95912-26 and Needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction (95886-26) needle 
electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction 
(95886-26) unlisted neurological or neuromuscular diagnostic procedure (95999) provided November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you had fallen and your care giver was 
unable to pick you back up. Your care giver called 911 for help and when the responders arrived, they assisted 
in getting you up. You say that calling 911 for assistance is all you have to rely on, and it is necessary to make 
sure that you are not hurt. You asked the Plan to reconsider providing payment. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 20, 2020. 
 
You asked the Plan to pay for the testing services. You say that enrollees who have Guardant360 testing are 
able to avoid a tissue biopsy. The Plan denied your request. The Plan says coverage of comprehensive genomic 
profile testing is limited to one test per specimen. 
 
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 the claim provided does not show that the coding and billing guidance has been followed. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 testing provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on February 21, 2020 by 
a non-participating provider. 
 
You asked the Plan to pay for the services. You say that the services were denied for not authorization on file, 
however, these services do not require authorization. The Plan denied your request. The Plan says there is no 
authorization for services. 
 
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 services provided to the enrollee on February 
21, 2020 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy, with biopsy (45380) and 
the Upper GI endoscopy, with biopsy (43239) provided on March 13, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $45 
copayment for each Medicare-covered specialist visit for surgery services furnished in a physician's office, 
certified ambulatory surgical center, hospital outpatient department, or any other location.  
 
You have been asked to pay a $45 copayment for a specialist office visit for surgery services provided in a 
physician?s office. The record shows that you were treated for an existing medical condition during your visit 
as biopsies were performed. This means that the services at issue are not considered preventive screenings. 
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 colonoscopy, with biopsy (45380) and the Upper GI 
endoscopy, with biopsy (43239) provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on February 18, 2020. 
 
You asked the Plan to pay for genetic test. You say that only the test requisition form is needed for testing. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because no notes were 
submitted by the ordering physician to determine the clinical utility of this testing. 
 
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 pay for genetic test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to guidelines, next-generation sequencing tests are recommended for enrollees with 
locally advanced or metastatic disease who are candidates for anti-cancer treatment. The documentation 
submitted does not indicate the stage of the enrollee's cancer or the status of the enrollee as a candidate for anti-
cancer treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous vertebral augmentation (PVA) provided on 
January 14, 2020. 
 
You asked the Plan to pay for the PVA. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered when all of the above criteria are 
met. 
 
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 pay for the PVA. Our reviewer says that the 
requested PVA is not medically reasonable and necessary. Our physician reviewer found that the onset of the 
enrollee's symptoms had been in July (when he reportedly suffered a fall) and services were not provided until 
almost 6 months later (January). An MRI from September 2019 also did not show any evidence of an acute 
compression fracture at that time either. This would not have been consistent with the requirements of the 
LCD. Furthermore, other requirements as set-forth in the LCD were not satisfied in this case. There was no 
evidence of a "Multidisciplinary team consensus" as defined by the LCD. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pay for the percutaneous vertebral augmentation (PVA) provided on January 14, 2020.