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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (SIJ) 
nerves. 
 
You asked the Plan to pre-approve the RFA procedure of the SIJ. You say that this would be a beneficial 
treatment. The Plan denied your request. The Plan says this is an experimental treatment. 
 
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 RFA procedure of the SIJ. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational.  Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 the RFA procedure of the SIJ have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (SIJ) nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is for safety, you are a fall risk. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on August 26, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this was billed with multiple codes which is not appropriate. Only 
several of the billed codes have been approved for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This NGS panel was not billed with a single genetic panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel 
provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 7, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that enrollee is a 72-year-old female who was diagnosed with stage IV metastatic lung cancer. As the 
goal is not to best cure the enrollee's condition, choosing the best medication would not be clinically significant and, therefore, the Guardant360 testing would also not be significantly clinically helpful in this setting. 
Therefore, this request for Guardant360 is considered 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
15, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not remember having 
this appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $65 
copayment for urgently needed services provided at an urgent care center.  
 
The record shows that you were evaluated and treated for loose bowel movements and abdominal pain. 
Therefore, you have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently Needed 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 waive the copayment for 
an urgent care visit provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the root canal provided by an out-of-
network (OON) dentist on January 17, 2022. 
 
You asked the Plan to make additional payment for the OON root canal services. You say that you were 
referred to this dentist and were not told he was OON. You feel that this should be processed as in-network. 
The Plan denied your request. The Plan says there is no evidence that you inquired about the network status of 
the provider at issue. This claim was processed correctly with the Plan paying 50% of the allowed amount. The 
provider is not required to accept the allowed amount as payment in full and may bill you for the rest. 
 
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, payments to OON providers are only 
up to a certain amount. You are responsible for additional fees charged by the OON dentist. Therefore, we 
decided that the Plan does not have to make additional payment for the root canal provided by an out-of-
network (OON) dentist on January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided on September 29, 2021. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you did not expect to receive bills from 
out-of-network doctors and technicians. The Plan denied your request. The Plan says the deductible amount 
was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says there is a $750 deductible which applies to x-rays.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to x-rays. This cost sharing is a contractual obligation 
that had not been met at the time the x-ray was received on September 29, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the x-ray provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's dental services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physician's dental services to be provided by the requested out-of-network 
provider. You say that there are no in-network dentist in your area. The Plan denied your request. The Plan 
says you do not have out-of-network benefits and there are multiple in-network providers that you would be 
able to see. 
 
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 dental services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's dental services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit wheels for a wheelchair (K0108). 
 
You asked the Plan to pre-approve the transit wheels. You say that this feature is medically necessary. The Plan 
denied your request. The Plan says this feature is for use outside the home, and is therefore non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve transit wheels for a wheelchair (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on November 15, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were unaware the provider was 
OON. The Plan denied your request. The Plan says the copayment applied 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 a $45 
copayment for An office visit.  
 
You have been asked to pay a $45 copayment for an office visit. An office visit falls within the 
Physician/Practitioner services, including doctors 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 an office visit on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided to you on December 8, 
2021. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the drug testing 
was 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 the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that enrollee is a 64-year-old female with long-term drug treatment for chronic pain (only oxycodone). 
Screening drug testing (urine) was positive for oxycodone, as expected. There was no indication from the 
documentation that there was an abnormal result from drug screening or history of unusual behavior suggesting 
drug abuse or other factors that would justify a confirmation test panel including drugs not pertinent to this 
case. Therefore, without sufficient support made for this request, the definitive drug testing will be considered 
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 the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided to you on December 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on January 10, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that  The Plan denied your request. 
The Plan says this item is not a covered benefit.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on January 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scleral lens, liquid bandage device (S0151). 
 
You asked the Plan to pre-approve scleral lens, liquid bandage device. You say that scleral lenses are medically 
necessary for this enrollee. The Plan denied your request. The Plan says these services are not covered by 
Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
  
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested items/services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
scleral lens, liquid bandage device (S0151).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for prothrombin time services provided on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for the prothrombin time. You say that you have not been charged 
for these services for over 20 years. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $250 
copayment for outpatient hospital services.  
You have been asked to pay $110, which is less than the $250 copayment for the prothrombin time. The 
prothrombin time 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 waive the copayment for prothrombin time services provided on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided on October 12, 2021. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you did not expect to receive bills from 
out-of-network doctors and technicians. The Plan denied your request. The Plan says the deductible amount 
was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says there is a $750 deductible which applies to x-rays.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to x-rays. This cost sharing is a contractual obligation 
that had not been met at the time the x-ray was received on October 12, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the x-ray provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional supplies for a Continuous Positive Air 
Pressure (CPAP) machine (A4604, A7028, A7029, A7030, A7031, A7032, A7033, A7035, A7036,  
A7038, A7039, A7045, A7046). 
 
You asked the Plan to pre-approve the CPAP supplies. You say that these accessories are medically necessary. 
The Plan denied your request. The Plan says since coverage criteria for the CPAP machine are no longer met, 
the requested supplies are not covered. 
 
 The Plan must follow Medicare rules. Medicare rules say that accessories used with a PAP device are covered 
when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has been adhering to 
CPAP therapy. The record does not show a clinical re-evaluation as required. Since the records do not show 
that the enrollee meets criteria for continued coverage of the CPAP machine, the supplies and accessories do 
not meet coverage criteria. Based on this information, we decided that Medicare rules for coverage of the 
CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
supplies for a Continuous Positive Air Pressure (CPAP) machine (A4604, A7028, A7029, A7030, A7031, 
A7032, A7033, A7035, A7036,  
A7038, A7039, A7045, A7046).
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 you need IRF care to remain at your current assisted 
living facility. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not 
been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a skilled nursing facility (SNF) admission.  
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 15, 2022, to 
April 25, 2022, and then again from May 4, 2022, to June 4, 2022. The Plan has covered 100 days of SNF care. 
 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have pre-approve a skilled nursing facility (SNF) admission. skilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on 
December 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is evidence of misrepresented services. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules say that durable medical equipment (DME) supplies must be 
provided with a proof of delivery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of durable medical equipment provided to 
the enrollee on December 21, 2021 have been met. A written order, itemized delivery ticket, itemized shipping 
invoice, proof of delivery, or any other documentation to validate an established relationship with the ordering 
physician and the enrollee was not provided in this case.. Therefore, we decided that the Plan does not have to 
pay for durable medical equipment provided to the enrollee on December 21, 2021.