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

 
We decided that the Plan does not have to pre-approve partial vulvectomy. 
 
You asked the Plan to pre-approve partial vulvectomy. You say that the surgery needed is not cosmetic. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 partial vulvectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a diagnosis of unspecified hypertrophy of vulva, as well as candidiasis of 
vulva and vagina. The preoperative visit documents that the "lower edge of the left labia minora is very very 
redundant and hypertrophic. It appears having a tear of the superfical skin and it is inflamed." The 
documentation does not support that you have failed conservative treatment of your condition. Therefore, you 
do not meet 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 partial vulvectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve partial vulvectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telephone evaluation and management services (99442) 
provided on June 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation and management services. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they were non-emergent and prior authorization was not obtained. 
 
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 Telephone evaluation and management services 
(99442) provided on June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for spinal injection provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for spinal injection. You say that you say that in the past she did 
not have to pay a copay. The Plan denied your request. The Plan says the cost sharing will be applied according 
to the Plan contract. 
 
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 $250 
copayment for Outpatient surgery/visit for surgical procedures.  
 
You have been asked to pay a $250 copayment for spinal injection. This item/service falls within the 
Outpatient surgery/visit for surgical procedures 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 spinal injection provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hydration services infusion provided on 
May 31, 2022. 
 
You asked the Plan to waive the copayment for a hydration services infusion. You say that the plan didn't pay 
anything towards this service. you should not owe more than the plan does for a service. The Plan denied your 
request. The Plan says this cost sharing was charged 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 outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $210.28 copayment, rather than the full copayment of $325 for a hydration 
services infusion. This item/service 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 hydration services infusion provided on May 
31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve Intracept intraosseous nerve ablation system. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows 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 Intracept intraosseous nerve ablation 
system. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has a history of longstanding back pain. 
The enrollee has failed conservative and surgical treatment of your pain with narcotic and anti-inflammatory 
pain medications, muscle relaxants, nerve pain blockers, antidepressants, therapy, massage, bracing, home 
exercise, and a low back fusion surgery in 2012. The Intracept procedure is experimental. More research is 
needed. Therefore, the enrollee does not meet 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 Intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of one knee cartilage using an endoscope. 
 
You asked the Plan to pre-approve removal of one knee cartilage using an endoscope. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 removal of one knee cartilage using an 
endoscope. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for derangement of medial 
meniscus due to an old tear. The enrollee presented with left knee pain that is located along the medial aspect 
of the knee. There is associated pain and stiffness. The left knee exam reveals full extension to 130 degrees of 
flexion. Tenderness over the medial joint line is noted. X-rays were noted to be reviewed of the left knee and 
showed limb alignment is slight varus, joint spaces demonstrate narrowing medially, the patella appears 
centrally located in relation to the trochlea, Kellgren-Lawrence grade 3, and no acute osseous abnormalities are 
noted. However, there is imaging evidence of tricompartmental osteoarthritis of the left knee. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the enrollee does not meet 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 removal of one knee cartilage using an endoscope have not been met. 
Therefore, we decided that the Plan does not have to pre-approve removal of one knee cartilage using an 
endoscope.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility medical visit provided on May 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility medical visit. You say that the staff were supposed to make 
sure this preauthorization was collected. Do not penalize this provider for the staff shortcomings. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
 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 a nursing facility medical visit provided on May 
23, 2022, 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 office visit on July 05, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for specialist visits. Covered services include consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $40 copayment for office visit. This item/service 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 office visit on July 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of your 
right hand without contrast dye (73200) provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not feel you should be 
responsible for the CT scan because the hospital did not do the proper test. You say your primary care 
physician (PCP) ordered a dual contrast CT scan. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. The medical records show you received the service at issue. 
 
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 $110 
copayment for advanced imaging services provided in an outpatient hospital facility.  
 
You have been asked to pay a $98.73 copayment for CT scan. This service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have been asked to pay less than 
the contractually required cost-share. You are only responsible for the lesser amount. 
 This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a computed tomography (CT) scan of your right hand 
without contrast dye (73200) provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on November 11, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an eye appointment. You say that you needed to be seen by this out-of-network 
provider because you do not have a car and had no way to get to another eye doctor within network because 
they are too far away. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 an eye appointment 
provided on November 11, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a tumor removal procedure provided on 
May 05, 2022. 
 
You asked the Plan to reduce the copayment for a tumor removal procedure. You say that you were told by the 
office you would only have a $35 copay. You are on a fixed income, and this copay would cause a hardship. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $195 
copayment for outpatient hospital services. 
 
You have been asked to pay a $195 copayment for a tumor removal procedure. This item/service falls within 
the outpatient hospital services 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 reduce the copayment for 
a tumor removal procedure provided on May 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided from January 3, 2022, to January 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dialysis services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says dialysis services are only covered for out-of-network providers when 
the enrollee is temporarily out of the area. A referral/authorization was not obtained prior to services being 
rendered. 
 
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 dialysis services provided from January 3, 2022, 
to January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a targeted genomic sequence analysis panel 
on March 12, 2022. 
 
You asked the Plan to waive the copayment for a targeted genomic sequence analysis panel. You say that you 
would like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for each Medicare-covered lab services for a targeted genomic sequence analysis 
panel. The total allowed amount of the targeted genomic sequence analysis panel is $5,000.00, resulting in a 
coinsurance amount of $1,000.00.  
The enrollee has been asked to pay a 20% coinsurance for each Medicare-covered lab services for a targeted 
genomic sequence analysis panel. This item/service falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a targeted genomic sequence analysis panel on March 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on July 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 surgical pathology services provided on July 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service January 24, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 72170 is bundled into 
payment for code 73501. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 
is a column II code to column I code 73501. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72170 billed for date of service January 24, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced leg pump device. 
 
You asked the Plan to pre-approve an advanced leg pump device. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when specific 
requirements 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 pre-approve an advanced leg pump device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the segmental pneumatic compression device at issue in this 
case meets all of Medicare's Local Coverage Determination (LCD): Pneumatic Compression Devices - L33829 
criteria for medically reasonable and necessary for the enrollee. Provided records do not clearly document the 
enrollee has been using the non-segmental pneumatic compression device (E0651) every day for multiple hours 
each day after careful, in-person fitting, training and supervision by a technician who is skilled in and who 
regularly and successfully uses the appliance provided as required 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 an advanced leg pump device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an advanced leg pump device.