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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. At this time, the procedure is not medically 
necessary for the enrollee 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided on 
December 21, 2021 and December 28, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were told that there 
was no copayment for each visit. The Plan denied your request. The Plan says the copayment amounts you are 
being charged are 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 $30 
copayment for each covered physical therapy visit. There were 2 visits, resulting in a total copayment of $60. 
 
You have been asked to pay $30 copayment for each physical therapy visit. Physical therapy visits fall within 
the Outpatient Rehabilitation 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 copayments for 
physical therapy visits provided on December 21, 2021 and December 28, 2021.  
 
Your complaint about receiving inaccurate information about the cost-share for these services is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 45 fractions of intensity modulated radiation therapy (IMRT.) 
 
You asked the Plan to pre-approve 45 fractions IMRT services. You say that 45 fractions are medically 
necessary and supported by the clinical information provided. The Plan denied your request. The Plan says that 
the doctor has requested a greater number of daily treatment doses than needed. The Plan says that 28 daily 
treatment doses are allowed for the enrollee's treatment course, and the request for more than 28 doses exceeds 
this limit. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve 45 fractions IMRT services. Our 
reviewer says that IMRT services are considered medically reasonable and necessary in this case. Our 
physician reviewer found for prostate cancer, National Comprehensive Cancer Network (NCCN) guidelines 
state that conventional fractionation remains an acceptable alternative 1.8-2 Gy for 37-45 fractions. Our 
physician reviewer found that in addition to the NCCN guidelines, ASTRO, ASCO, and AUA evidence-based 
guidelines consider 45 fractions acceptable. Our physician reviewer found that the standard of medical 
necessity criteria are met as the treatment with 4 fractions of IMRT would be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 45 fractions IMRT services have been met. Therefore, we decided that the Plan 
has to pre-approve 45 fractions of intensity modulated radiation therapy (IMRT.)  
 
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 Gocovri. 
 
You asked the Plan to pre-approve Gocovri. You say that the clinical documentation and the medical journals 
submitted support the need for the requested drug The Plan denied your request. The Plan says the requested 
drug is an oral capsule that is self-administered. The Plan says that the enrollee does not have pharmacy 
benefits administered under this contract. The Plan says that the enrollee does have TRS-Care Medicare 
Advantage which provides its own pharmacy benefits. 
 
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 Gocovri.   
Benefits for Gocovri 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on January 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you are out-of-network, however, the enrollee cannot 
choose which radiologist reads their diagnostic test. 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 x-
ray at issue. We found no exception that would require the Plan to pay for the x-ray. The records provided for 
review do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to 
pay for the x-ray provided on January 6, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0428) provided on January 25, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services 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 $225 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $225 copayment for the ambulance transportation services. 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 ambulance transportation services (A0425, A0428) provided on 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says radiofrequency ablation for sacroiliitis has not been shown to provide a clear long-term 
benefit. 
 
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 Our physician 
reviewer found that you have sacroiliitis. radiofrequency ablation of the sacroiliac joint is considered 
experimental/ investigational because of the wide variation in efficacy reported in the peer reviewed literature.  
Therefore, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs and was alert with confusion. The enrollee was at a moderate to maximal 
assist level for functional mobility including gait to short distances. The enrollee does not require skilled 
nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myelography lumbar injection provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for myelography lumbar injection. You say that with all the issues 
with the providers there should be a $0 responsibility. 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 $340 
copayment for each Medicare-covered outpatient surgery at an in-network ambulatory surgical center or a 
hospital outpatient facility.  
 You have been asked to pay $340 copayment for the myelography lumbar injection. The myelography lumbar 
injection 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 
myelography lumbar injection provided on November 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasonic guidance for needle placement (76942) 
provided on December 6, 2021. 
 
You asked the Plan to pay for code 76942. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76942 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Ultrasonic guidance for needle placement (76942) provided 
on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 laboratory services provided on November 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (86021) 
provided on November 27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for Ambulance services.  
 
The enrollee has been asked to pay a $225 copayment for the ambulance transportation services. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for ambulance transportation services (86021) provided on 
November 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you received a letter from the 
enrollee's State Medicaid Agency stating that claims incurred 3 months prior to getting approved for Medicaid 
would be waived or reimbursed. The Plan denied your request. The Plan says the copayment amount the 
enrollee is being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $300 copayment for inpatient stay.  
 
The enrollee has been asked to pay $300 copayment for inpatient stay. Inpatient stay falls within the Inpatient 
Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
October 26, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $192.45 copayment for an outpatient hospital visit, which is less than the 
standard $295. 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 outpatient hospital visit provided on 
October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (73502, 72110, 73630) provided 
on July 1, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services 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 $110 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $104.98 copayment for an x-ray, which is less than the standard $110. X-rays 
fall 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 an x-ray (73502, 72110, 73630) provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthroscopy provided on March 15, 
2022. 
 
You asked the Plan to waive the copayment for the arthroscopy. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services 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 $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $325 copayment for the arthroscopy. Arthroscopys fall 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 arthroscopy provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the drug testing provided on January 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the drug testing. You say that the services were medically 
necessary. 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 
office visit and the drug testing. We found no exception that would require the Plan to pay for the office visit 
and the drug testing. The records provided for review do not show that office visit and the drug testing were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and the drug 
testing provided on January 24, 2022, by an out-of-network (OON) provider.