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

 
We decided that the Plan does not have to pay for the screening total body computed tomography (CT) scan 
(76497) provided on June 17, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the full body CT scan was not medically necessary. 
 
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 pay for the CT scan. Our reviewer says that the CT 
scan was not medically necessary. Our physician reviewer found the provided documentation does not indicate 
the clinical value and effectiveness of screening of a total body CT scan in the setting of a benign and 
asymptomatic process has not been demonstrated as a standard of medical practice. Therefore, the reviewer 
found that the CT Scan 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the screening total body computed tomography (CT) scan (76497) provided on June 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for an endoscopy performed on 
September 16, 2021. 
 
You asked the Plan to waive the $250 copayment for an endoscopy performed on September 16, 2021. You say 
that that you were unaware of the cost of this service. The Plan denied your request. The Plan says you must 
pay a $275 copayment per day for diagnostic radiology services that are not ultrasounds. 
 
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 $250 coinsurance for an endoscopy.  
 
The enrollee has been asked to pay a $250 coinsurance for an endoscopy. An endoscopy falls within the 
Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 $250 copayment for an endoscopy performed on 
September 16, 2021.
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 coverage criteria has 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 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's functional status and injury do not require intensive rehabilitation to 
restore function and her capacity to tolerate intensive therapy is limited.  
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 pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections are not medically necessary based 
on the Medicare LCD. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint procedures in patients for the indication of 
generalized pain conditions (such as fibromyalgia) or chronic centralized pain syndromes are considered not 
reasonable and 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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that there are multiple 
other possible pain generators here and these have not been addressed. The presence of other pain generators 
does not meet the criteria of the Medicare LCD and therefore, the request 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel test provided to the enrollee on 
October 10, 2021. 
 
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the Tempus gene panel test provided to the enrollee on October 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, immune globulin (Privigen), intravenous, non-
lyophilized (e.g., liquid), 500 mg provided on December 13, 2021. 
 
You asked the Plan to pay for injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 
500 mg. The Plan denied your request. The Plan says the injection is 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 pay for injection, immune globulin (Privigen), 
intravenous, non-lyophilized (e.g., liquid), 500 mg. Our reviewer says that the injection, immune globulin 
(Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that based on the medical records provided and the 
Medicare-approved major drug compendia, there is inadequate documentation that the Privigen at issue in this case meets Medicare criteria for medically reasonable and necessary. The provided records do not document 
adequate documentation with regard to the diagnosis of hypogammaglobulinemia and the safety, efficacy and 
medical necessity of the Privigen for this enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., 
liquid), 500 mg have not been met. Therefore, we decided that the Plan does not have to pay for injection, 
immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg provided on  
December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast biopsy surgery provided on October 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the breast biopsy surgery. You say that you are requesting reconsideration of 
payment based on the acute medical necessity of the enrollee. The Plan denied your request. The Plan says no 
prior authorization was 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 did not pre-approve the 
breast biopsy surgery. We found no exception that would require the Plan to pay for the breast biopsy surgery. 
The records provided for review do not show that the services at issue we breast biopsy surgery was urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the breast biopsy surgery provided on 
October 29, 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 hyperbaric oxygen under pressure, full body chamber, 
per 30 minute interval (G0277) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not one of the covered indications for hyperbaric oxygen. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy can be covered if the 
enrollee has a Medicare approved condition.  
 
We looked at the file and Medicare rules. Hyperbaric oxygen therapy has been requested for acute 
sensorineural hearing loss, which is not a Medicare approved condition. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (G0277) 
for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA nerves innervating the SI joint, with image 
guidance (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says radiofrequency nerve ablation of the sacroiliac joint is considered experimental, 
investigational or unproven and it therefore, not covered. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency nerve ablation of the SI joint is considered experimental, investigational; 
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 the service have not 
been met. Therefore, we decided that the Plan does not have to pre-approve RFA nerves innervating the SI 
joint, with image guidance (CPT code 64625).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 27, 2021, to 
August 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that authorization was not obtained for the services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 27, 2021, to August 30, 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at 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 
inpatient rehabilitation facility. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you had partial dentures previously, 
resulting in some of your teeth to fall out. You are unable to eat properly, and you have pain. You are 
requesting to get this work done to fix the damage. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 10, 2021. Therefore, 
we decided that the Plan does not have to pre-approve partial upper denture (D5211) and a partial lower 
denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual physical rendered on December 28, 2020. 
 
You asked the Plan to pay for these services. You say that you were told that this was covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare will pay for only one initial preventive 
physical examination per beneficiary per lifetime. 
 
We looked at the file and Medicare rules. The services at issue are an annual physical exam. Medicare covers 
one physical exam per beneficiary per lifetime, but annual physicals are not covered. Therefore, we decided 
that the Plan does not have to pay for the annual physical rendered on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas NEO GeneSys device provided to the enrollee 
on November 17, 2020. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary, per the 
enrollee's medical condition. The Plan denied your request. The Plan says the medical records do not document 
any clinical physical findings consistent with disuse atrophy or a spinal cord injury. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case the patient underwent treatment/therapy with the Sanexas NEO GeneSys device/system 
for their chronic pain. This device (or combination of device and services) has not validated in well designed 
clinical studies in current literature. While the device has FDA 510(k) clearance, it has not been shown to be as 
effective as other standard therapies for management of neuropathic pain. The use of this device is not 
otherwise readily consistent with the generally accepted standard of practice or care. As such it would not be medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Sanexas NEO GeneSys device provided to the enrollee on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 18, 
2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you have filed an appeal to 
dispute the cost share for outpatient surgery services provided by a plan participating provider. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 an outpatient hospital facility visit per date of service.  
 
 
 You have been asked to pay a $350 copayment for outpatient surgery. The outpatient surgery falls within 
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 outpatient surgery provided 
on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 vaccinations (0001A, 0002A) provided on April 
8, 2021, and May 8, 2021. 
 
You asked the Plan to pay for COVID-19 vaccinations. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The plan must follow Medicare rules. The rules say that Original Medicare was responsible for payment of the 
COVID-19 vaccine in calendar years 2020 and 2021. Both of the vaccine doses were received in 2021. The payment for these doses would be the responsibility of 
Original Medicare. Therefore, we decided that the Plan does not have to pay for COVID-19 vaccinations 
(0001A, 0002A) provided on April 8, 2021, and May 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facial feminization surgery. 
 
You asked the Plan to pre-approve the facial feminization surgery. You say that the facial feminization surgery 
is extremely important and medically necessary for you. The Plan denied your request. The Plan says 
procedures to primarily for feminization or masculinization are considered cosmetic (aesthetic). 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the facial feminization surgery. Our 
reviewer found the record does not indicate that you have dysfunction of a malformed body member or that the 
requested procedure is for the purpose of repair of accidental injury or to improve the functioning of a 
malformed body member, The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 
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 facial feminization surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the facial feminization surgery.