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

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request exceeds the one-way mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles one-way each trip. 
 
We looked at your request, the records in the case file, and the rules. The requested trip is over 50 miles one-
way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not 
been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation 
mileage
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphin sub 8mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is a benefit exclusion. 
 
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 Buprenorphin sub 8mg for 
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil 200 mg tablet. 
 
You asked the Plan to pre-approve Modafinil. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this medication does not fall under Part B. 
 
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 Modafinil 200 mg tablet.  
 
Benefits for Modafinil 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa 1 gm capsule. 
 
You asked the Plan to pre-approve Vascepa. You say that this service is medically necessary. The Plan denied 
your request. The Plan says your drug coverage is limited to those drugs covered under your medical benefit 
only. 
 
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 Vascepa 1 gm capsule.  
 
Benefits for Vascepa 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on January 31, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you do not think that you should 
have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $20 copayment for an ultrasound. The correct copayment has been applied to the 
services that were provided. An ultrasound falls within the outpatient diagnostic tests benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 23, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency room services on the date of service at issue in this 
appeal. The Plan says the correct copayment has applied per your contract with the Plan. 
 
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 $75 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on August 23, 2020. You have been asked to pay a $75 copayment for the emergency room services. 
The emergency room services fall within the Emergency care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency room services provided on August 23, 2020.
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 this service is medically necessary. The Plan denied 
your request. The Plan says rules for IRF care have not been met. 
 
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. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 4, 2020. 
 
You asked the Plan to pay for the ambulance services. 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 July 4, 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 provided  on July 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve outpatient ablation of the pulmonary vein. 
 
You asked the Plan to pre-approve outpatient ablation of the pulmonary vein. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 outpatient ablation of the pulmonary 
vein. Our reviewer says that the requested items/services are considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has recurrent symptomatic atrial fibrillation (AF) which is 
likely causing rate related depression of the enrollee's cardiac function. The enrollee is very symptomatic when 
in atrial fibrillation as well. Many of the anti-arrhythmics used for suppressing AF would be contraindicated as 
well given the enrollee's depressed LV function. In addition, AF ablation has been emerging in both published 
data and guidelines as a very reasonable consideration for initial therapy in selected candidates whose clinical 
situation warrants it and most especially when there are contraindications to other medical therapies as is the 
case here, given the depressed LV ejection fraction and the need to fully suppress the AF given its negative 
effect on this cardiac function. CMS rules require the procedure is safe, effective, appropriate and medically 
necessary in this situation. The pulmonary vein AF ablation planned here meets all those criteria in this clinical 
situation. Therefore, the enrollee meets criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient ablation of the pulmonary vein have been met. Therefore, we decided 
that the Plan has to pre-approve outpatient ablation of the pulmonary vein.  
 
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve Catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458). You say that cardiac catheterization is needed for further evaluation of the enrollee to assess for new 
ischemia. The Plan denied your request. The Plan says that the clinical records received do not support the 
medical necessity of the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Catheter placement in coronary 
artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 
supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left 
ventriculography, when performed (93458). Our reviewer says that the requested services are considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the records the patient 
has increased coronary risk, ongoing chest pain and a nuclear stress test that is equivocal for apical ischemia.  
In this setting of ongoing symptoms and equivocal/uninterpretable findings on stress testing a diagnostic 
cardiac catheterization is reasonable and medically necessary. Current guidelines also consider cardiac 
catheterization appropriate in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458) have 
been met. Therefore, we decided that the Plan has to pre-approve cardiac catheterization.  
 
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 pay for lead wires (A4557) provided on September 28, 2020. 
 
You asked the Plan to pay for the lead wires. You say that you would like reconsideration because the lead 
wires are separately reimbursable. The Plan denied your request. The Plan says since a TENS unit has been 
purchased in the previous 12 months, the lead wires have been denied. 
 
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 the lead wires. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a separate set of new leads is not justified on the basis of what was submitted. 
 
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 lead wires have not been met. Therefore, we decided that the Plan does not 
have to pay for lead wires (A4557) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0150 and D4341) received on August 25, 
2020, September 4, 2020 and September 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request. 
The Plan says this claim exceeds the maximum allowed per period. 
 
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. The Plan covers dental 
services with certain specific benefit limitations. 
 
D0150 was previously received on June 5, 2019, less than three years ago. D4341 was previously received in 
the same quadrants on on July 7, 2019 and July 18, 2019, less than two years ago. Based on this information, 
we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for dental services (D0150 and D4341) received on August 25, 2020, September 4, 
2020 and September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 physician services provided on January 24, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the chest, abdomen, and pelvis 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 the requested scan is not supported by evidence-based guidelines. 
 
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 not medically reasonable or necessary. Our physician reviewer found the enrollee had his 
bladder cancer diagnosed in 2018 with dual therapy completed in August, 2018. He has had CT scans of the 
chest, abdomen and pelvis in 2019 which revealed a new 4mm nodule in the right lower lobe but no nodules 
were seen on followup chest CT scans 1/9/20 or 7/15/20. The CT exams of the abdomen and pelvis have been 
negative with the exception of uniform bladder wall thickening. Further clinical information is lacking 
concerning the results of cystoscopy every 6 months but there are no notes to indicate cystoscopic suspicion of 
cancer recurrence. The NCCN guidelines, Version 6.2020 advocate CT of the chest, abdomen and pelvis 
annually beginning year 3 after diagnosis and treatment if there is no clinical finding to suggest recurrence. Per 
NCCN guidelines the patient would be eligible for his annual CT battery of tests in July, 2021. 
 
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, abdomen, and pelvis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the electric seat lift mechanism (E0627) and 
the sales tax (S9999) rendered by the out of network (OON) provider on July 17, 2020. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the seat lift mechanism was rendered by an 
out of network provider, without prior authorization. Additionally, the provider is not certified by Medicare. 
 
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. Additionally, no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the item at issue in this appeal. The Plan did not pre-approve this item at issue. We 
found no exception that would require the Plan to pay for this item. Additionally, the provider does not 
participate in the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement 
for the electric seat lift mechanism (E0627) and the sales tax (S9999) rendered by the out of network (OON) 
provider on July 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on August 31, 
2019. 
 
You asked the Plan to pay for ambulance services. You say that payment of the ambulance bill should be 
reconsidered. The Plan denied your request. The Plan says rules for payment have not been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transportation have not been met. Specifically, the record shows that the enrollee 
was an inpatient on the date of service at issue. This means that the transportation services are covered under 
Part A, and separate payment is not due from the Plan. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0427, A0425) provided on August 31, 2019.