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

 
We decided that the Plan does not have to pay for an office visit provided on September 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so the claim 
should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider with no in-network referring provider. Also, the services provided were not urgent or emergent. 
  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 office visit provided on September 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lateral sacral branch nerve blocks at S2 and S3. 
 
You asked the Plan to pre-approve lateral sacral branch nerve blocks at S2 and S3. You say that you would like 
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan 
says the requested nerve blocks are 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 lateral sacral branch nerve blocks at S2 
and S3. Our reviewer says that the enrollee has diagnoses of Sacroiliitis, Lumbar radiculopathy, Spondylosis 
without myelopathy or radiculopathy, in the lumbar region. A previous left SI joint injection decreased pain 
level by 50%. Our physician reviewer found there is insufficient evidence in the peer-reviewed medical 
literature to demonstrate that lateral sacral branch nerve blocks at S2 and S3 are medically reasonable and 
necessary 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 lateral sacral branch nerve blocks at S2 and S3 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve lateral sacral branch nerve blocks at S2 and S3.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on November 9, 2021. 
 
You asked the Plan to waive the copayment for an EGD. You say that you thought that this was a screening 
like a colonoscopy is. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct amount. 
 
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 $350 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
 
 The record shows that you received an EGD at an ambulatory surgical center on November 9, 2021. An EGD is 
considered an outpatient surgical procedure and is not a screening. Therefore, you are responsible to pay the 
$350 copayment.  
 
You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery, 
including 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 an EGD provided on November 9, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a positron emission tomography (PET) scan. 
 
You asked the Plan to pay for a PET scan. The Plan denied your request. The Plan says that a PET scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a PET scan. Our reviewer says that a PET 
scan is medically reasonable and necessary. Our physician reviewer found that on December 1, 2020, the Food 
and Drug Administration (FDA) approved the radioactive tracer Gallium (Ga) 68 PSMA-11 for use in PET 
imaging of men with prostate cancer. Under the approval, the tracer can be used in PET imaging for prostate 
cancer that is suspected of having spread to other parts of the body. Ga 68 PSMA-11 can also be used in men 
who have been treated successfully for prostate cancer but, because of elevated PSA levels, their disease is 
suspected of having returned. The requested PET scan is medically necessary to rule out initial spread. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan has to pay 
for a positron emission tomography (PET) scan.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is highly motivated with therapy 
services in order to increase independence and safety, in order to return home and to work. The Plan denied 
your request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 there are no acute rehabilitation or nursing needs identified 
or documented in the record. The enrollee is medically stable with no new stroke and does not need physician 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. At the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy. IRF admission is not medically necessary based on lack of medical complexity, and lack of acute 
rehabilitation and nursing needs and high functional level. 
 
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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 enrollees medical conditions are stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. The enrollee does not require the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility 
level appears to be appropriate in this case. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93970) provided on August 28, 2021. 
 
You asked the Plan to pay for the extremity study. You say that the service was medically necessary. The Plan 
denied your request. The Plan says screening services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that extremity studies are only considered medically 
reasonable and necessary for specific diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extremity study have not been met. Specifically, the file shows that the diagnosis code is not 
listed as a medically necessary diagnosis. Therefore, we decided that the Plan does not have to pay for the 
extremity study (93970) provided on August 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the upper gastrointestinal endoscopy with 
biopsy (43239) provided on May 19, 2021. 
 
You asked the Plan to waive the copayment for the upper endoscopy procedure. You say that you were led to 
believe this service would not require a copayment, and you would not have had it done if you knew you would 
be responsible for this cost. The Plan denied your request. The Plan says this claim was processed correctly, 
and your copayment was assessed in accordance with your contract. The Plan also confirmed with the provider 
that you were notified of the expected $250 copayment on May 17, 2021, via phone. 
 
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 surgical procedures provided in an outpatient hospital setting.  
 You have been asked to pay a $250 copayment for the upper endoscopy procedure. The upper endoscopy is 
classified as a surgical procedure and was provided in an outpatient hospital setting. 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 upper gastrointestinal endoscopy with biopsy (43239) provided on May 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on September 28, 2021, and 
October 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you did not know that your follow up visits 
were with an out-of-network provider. The Plan denied your request. The Plan says the claim processed 
correctly, and the provider was an out-of-network provider. 
 
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 outpatient services provided on September 28, 
2021, and October 20, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313) for use with an approved power wheelchair. 
 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 wheelchair should be approved, but there is no need for an expandable controller. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The 
enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The enrollee has three power options of tilt, recline, and power elevating leg rests but the patient does 
not need to control the power options through a joystick. The enrollee's upper extremity strength and function 
support that the enrollee can control any power options through their own switches. 
 
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 an expandable controller (E2377) with related electronic connections (E2311) and harness 
(E2313) for use with an approved power wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the complete electrocardiogram (93000) provided on 
August 5, 2021. 
 
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 that the copayment has been applied correctly 
to the service 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 does not say in clear and accurate terms 
how much cost sharing you should expect to pay for diagnostic tests.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a specific 
copayment for diagnostic tests as the contract states that you must pay $0 to a $50 copayment for these 
services. The Plan contract does not clearly say how much cost sharing enrollees must pay for diagnostic tests. 
This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, 
we decided that the Plan has to waive the copayment for the complete electrocardiogram (93000) provided on 
August 5, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron ODT for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Ondansetron ODT for the 
enrollee.  
 Benefits for this drug 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: 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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the criteria for coverage of IRF care. The Plan says that the 
enrollee does not require 3 hours of therapy per day or specialized training or equipment of an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 enrollee does not require at least 3 hours a day / 5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The enrollee will not 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on November 10, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that due to taking arthritis medication and being 
diabetic you need an eye test every year. The Plan denied your request. The Plan says the eye refraction is not 
covered by Medicare or under your Plan contract. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that you know that the requested device will help 
with your daily living and chronic pain. The Plan denied your request. The Plan says rules for coverage for a 
TENS device have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for CLBP will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Specifically, the documentation indicates that the request is for 
treatment of CLBP. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous 
electrical nerve stimulation (TENS) device.