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

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) of the heart with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says imaging to measure the amount of calcium deposits in the blood vessels that 
supply blood to your heart muscle (quantitative calcium scoring) is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at 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 pre-approve 
the computed tomography (CT) of the heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a domiciliary or rest home visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a domiciliary or rest home visit. You say that you provide care to 
homebound and bed bound individuals, a service that is unique and no other provider that can be found within 
your network offering the same service. The Plan denied your request. The Plan says the member is requesting 
to see an out-of-network dermatologist for the evaluation of a skin condition, and there is no documentation 
that this is an emergent situation. The Plan also says that they have network providers available who can 
provide the dermatological services this member requires. The Plan also says that the member is wheelchair 
bound, but they have verified with the assisted living facility that the member is not bed bound and is able to 
see providers in their office, and there are many in-network dermatologists within the designated maximal 
time/distance parameters. 
 
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 domiciliary or rest home visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bathtub wall rail provided on August 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a bathtub wall rail. You say that you looked back at the booklet, and it says you 
are able to get the over the counter standard grab bar, and nothing is said about where you have to buy it from. 
You also say that on the Plan website, preventing falls states getting bathroom safety equipment, but nowhere 
does it say you have to get this from a contracting provider. The Plan denied your request. The Plan says based 
on a review of the information received, it was determined that the bathroom grab bars rendered on August 4, 
2021, were purchased from an out-of-network supplier. The Plan also says that you did not contact them prior 
to inquire about in-network suppliers and sales tax is not covered. 
 
 
 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 bathtub wall rail provided on August 4, 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 the Lumbar/Sacral Facet Joint Block. 
 
You asked the Plan to pre-approve the Lumbar/Sacral Facet Joint Block. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that Facet joint interventions done without CT or 
fluoroscopic guidance are considered not reasonable and necessary. This includes facet joint interventions done 
without any guidance, performed under ultrasound guidance, or with magnetic resonance imaging (MRI). 
 
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 Lumbar/Sacral Facet Joint Block. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not meet the criteria for coverage. 
 
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 Lumbar/Sacral Facet Joint Block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Lumbar/Sacral Facet Joint Block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 March 3, 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 laboratory services provided on November 
4, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered 
because lab work was required as part of your annual physical. You say that you would like this to be appealed. 
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 $10 
copayment per day for Medicare-covered outpatient diagnostic tests. You will pay only one copayment per day 
even if multiple tests are performed.  
 You have been asked to pay a $10 copayment for laboratory services. Laboratory services falls within the 
Outpatient diagnostic and therapeutic services and supplies 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 laboratory services provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
January 6, 2022. 
 
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 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 clearly says that you must pay a $50 
copayment for provider and professional services rendered at a specialists office.  
 
 
 You have been asked to pay a $50 copayment for the provider and professional services rendered at a 
specialists office. 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 office visit (99213) provided 
on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee has tried many other 
treatments without much relief until the spinal cord stimulator trial. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because the enrollee does not meet the Medicare 
criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered if certain 
criteria 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer 
found detailed documentation is not evidence regarding a return of lumbar deficits demonstrated on objective 
examination to support the need for spinal cord stimulation. Additionally, there is no documentation of recent 
failure of physical therapy or medications. There is no compelling rationale or extenuating circumstance noted 
to support the necessity of this procedure as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional physical therapy is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the requested physical therapy services 
are not medically necessary. The enrollee was previously approved for 20 visits, which have been used. There 
is insufficient information to support that the enrollee needs ongoing services from a skilled therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's medical condition and therefore are not 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional physical therapy (PT) visits.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and the enrollee's status is stable and improving. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current 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 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 seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that this is necessary due to your conditions. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you 
are not documented as unable to rise from any chair in your home. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer says 
that you do not meet the Medicare criteria for a seat lift mechanism. Our physician reviewer found the 
physician's prescription states that you are able to perform sit-to-stand transfers and there is no other 
documentation to support that you require assistance with sit-to-stand transfers (or inability to stand from a 
chair in the home). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a seat lift mechanism.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on February 16, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration of the denied 
claim based on being a participating provider with Medicare and you provided the medical care to the enrollee. 
The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was 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 the therapy services provided on February 16, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage chair (E1399). 
 
You asked the Plan to pre-approve a massage chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
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 massage chair (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on January 13, 2022, and 
January 20, 2022. 
 
You asked the Plan to waive the copayment for MRI's. You say that you would like the Plan to change the 
copayment to $100 because you are having severe hardship right now. The Plan denied your request. The Plan 
says coinsurance is correct. 
 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasound. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed.  
 
You have been asked to pay $550.18 for MRI's ($275.09/each x 2 MRIs = $550.18). You have been asked to 
pay $275.09, which is less than the standard $325 copayment for an MRI. MRI's falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 MRI provided on January 13, 2022, and January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from September 19, 
2021, through September 24, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you are on a fixed income, 
and you cannot afford to pay this bill. The Plan denied your request. The Plan says coinsurance is correct. 
 
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 $390 
copayment for each Medicare-covered day, for days 1-5 and a $0 copayment for each additional day for 
inpatient stay.  
 
  You have been asked to pay $1,950 for the inpatient hospital stay ($390/day x 5 days = $1,950). The inpatient 
hospital stay falls within the Inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay from September 19, 2021, through September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM sensor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 CGM sensor have not been met. Specifically, the requested item is a non-preferred 
brand. The case record does not contain medical documentation that supports the medical necessity of the 
requested item. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test provided on January 19, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug test. You say that you would like to appeal the denial of the claim. The Plan 
denied your request. The Plan says the provider is out-of-network and authorization is required prior to an out-
of-network visit. 
 
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 drug test provided on 
January 19, 2022 by an out-of-network (OON) provider.