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

 
We decided that the Plan does not have to pay for specialist office visit provided on March 16, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for specialist office visit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for these 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 specialist office visit provided on March 16, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that this will provide 
longer pain relief for the enrollee. The Plan denied your request. The Plan says this is experimental. 
 
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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental/ investigational and therefore is 
deemed not medically reasonable or 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is 
ineligible to bill Medicare services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. The provider in question does not participate in the Medicare 
program, and is not payable for Medicare 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 the 
services provided on February 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of the CT angiography of the head and neck and chest 
x-rays provided on May 24, 2020. 
 
You asked the Plan to pay for the imaging interpretations. You say that you believe that this should be covered. 
The Plan denied your request. The Plan says that this was correctly denied since the provider billed with an 
inpatient place of service when you were approved only for outpatient observation care. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan is also required to submit sufficient information to support its denial. 
 
In this case, these services were rendered by a radiologist associated with a network facility. You had no 
control over how these services were billed. Moreover, there is no evidence whether the facility billed this stay 
as inpatient or outpatient. While outpatient care may have been approved, this does not mean that you were not 
an inpatient at the time of these services, meaning that there is not sufficient evidence to show that the place of 
service code used by this radiologist was incorrect. As such, these services are considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the interpretation of the CT angiography of the head 
and neck and chest x-rays provided on May 24, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 6, 
2020 and billed under code 36901. 
 
You asked the Plan to pay for physician services provided to the enrollee. The Plan denied your request. The 
Plan stated that while code 37238 was paid, code 36901 or 'introduction of a catheter into a hemodialysis 
circuit with angiography of the dialysis graft' was not documented in the operative notes provided. The Plan 
states this code is not substantiated by the clinical documentation in the operative report submitted for review.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes and provide medical records to support the 
services billed. In this case, the records provided do not support the services billed in regard to code 36901. 
Medicare rules for coverage of code 36901 were not met.  Therefore, we decided that the Plan does not have to 
pay for physician services provided to the enrollee on February 6, 2020 and billed under code 36901.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for hydromorphone from an 
out of network pharmacy. 
 
You asked the Plan to pre-approve hydromorphone from an out of network pharmacy. You say that this service 
is medically necessary. The Plan denied your request. The Plan says an in-network exception cannot be made 
as the drug is being furnished by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve an in-network exception for hydromorphone from an out of network 
pharmacy.  
 
Benefits for hydromorphone from an out of network pharmacy 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 250 Mg Abiraterone Acetate Tablets. 
 
You asked the Plan to pre-approve the Abiraterone Acetate Tablets. You say that you would like 
reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug 
is not covered for the member's condition under Medicare 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 250 Mg Abiraterone 
Acetate Tablets.  
 
Benefits for the Abiraterone Acetate Tablets 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the MRI of the brain stem provided on May 25, 
2020. 
 
You asked the Plan to pay for the MRI interpretation. You say that you believe that this should be covered. The 
Plan denied your request. The Plan says that this was correctly denied since the provider billed with an 
inpatient place of service when you were approved only for outpatient observation care. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan is also required to submit sufficient information to support its denial. 
 
In this case, these services were rendered by a radiologist associated with a network facility. You had no 
control over how these services were billed. Moreover, there is no evidence whether the facility billed this stay 
as inpatient or outpatient. While outpatient care may have been approved, this does not mean that you were not 
an inpatient at the time of these services, meaning that there is not sufficient evidence to show that the place of 
service code used by this radiologist was incorrect. As such, these services are considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the interpretation of the MRI of the brain stem 
provided on May 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart rhythm procedure (92960, 96374) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a heart rhythm procedure to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria has not been met. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a heart rhythm procedure (92960, 96374) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the acute care hospital with acute hypoxemic 
respiratory due to acute respiratory distress syndrome (ARDS)/pneumonia, and required noninvasive positive 
pressure ventilation. The enrollee has been treated with antibiotics and Solu-Medrol. On November 11, 2020, 
the enrollee was in no apparent distress. The enrollee is still dependent on bilevel positive airway pressure 
(BiPAP). Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, 
LTACHs do not provide clinical services that are materially different than those of short term acute care 
hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning pillow. 
 
You asked the Plan to pre-approve these services. You say that you have low back pain. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a positioning pillow.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve ultrasound guided joint injections (20606). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says that coverage criteria is not met. 
 
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 the injections. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure can potentially be used in lieu of surgery. Therefore it is indicated as a final non-surgical 
option. 
 
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 injections have been met. Therefore, we decided that the Plan has to pre-
approve ultrasound guided joint injections (20606).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
cleaner. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
cleaner.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is needed to assess candidacy for 
radiofrequency ablation. The Plan denied your request. The Plan says there is associated radiculopathy in the 
leg and thigh. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has radicular symptoms, which does not meet the criteria to perform diagnostic medial 
branch blocks. The requested procedure is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a medial branch block for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says the device cannot be used in the home. 
 
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 patients 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 vehicle. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found the device may not be 
able to be operated in the trailer. It is not clear how it would be able to enter and leave the trailer. Therefore, the 
request is considered not medically reasonable or 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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you want to be treated by the out-of-
network provider. The Plan denied your request. The Plan says they have in network providers who can 
provide these 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 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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management 
specialist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee does not wish to see the referred 
provider. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 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 confirmed that there is a pain 
management specialist available that the enrollee has not previously seen. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve a referral to an out-of-network pain management specialist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on 
August 3, 2020 at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that since you were not 
advised that this service was not covered in full that the copayment should be waived. The Plan denied your 
request. The Plan says you were charged this copayment 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 $325 
copayment for surgery in an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the surgery in an outpatient hospital facility 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 diagnostic colonoscopy you had on August 3, 2020 at an outpatient hospital facility.