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

 
We decided that the Plan does not have to pre-approve in-home infusion services. 
 
You asked the Plan to pre-approve in-home infusion services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says your provider confirmed that you do not 
meet homebound criteria. The Plan confirms there is an outpatient facility that is only 5.4 miles away from 
your residence where you can continue receiving your infusion services. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve in-home infusion services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on December 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on December 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (ER) provided on 
December 5, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as the 
enrollee 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 $90 copayment for Emergency care.  
 
 
  The enrollee has been asked to pay a $88.02 copayment for the ER visit, which is less than the standard $90. 
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 emergency room visit (ER) provided on 
December 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive coinsurance for the osteogenesis stimulator provided on 
August 13, 2020. 
 
You asked the Plan to waive coinsurance for the osteogenesis stimulator. You say that your provider told you 
this was covered in full, and you don't have the money to pay your 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 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies.  
 
  You have been asked to pay $717, which is 20% of the allowed amount for the osteogenesis stimulator. The 
allowed amount is $3,585 (20% x $3,585 = $717). The osteogenesis stimulator falls within the Durable 
medical equipment (DME) and related 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 
coinsurance for the osteogenesis stimulator provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided March 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed code is included in another code already paid. 
 
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 CPT code 83789 is not supported in the medical record. Specifically, the billed code is included in 
codes  80307 & G0480 which were already approved. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (83789) provided March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat bariatric surgery (CPT code 43775). 
 
You asked the Plan to pre-approve the repeat bariatric surgery. You say that the surgical procedure is medically 
necessary. The Plan denied your request. The Plan says the documentation indicates that repeat bariatric 
surgery is generally not reasonable and necessary and Medicare does not provide prior authorization for these 
services as per the LCD. 
 
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 repeat bariatric surgery. Our 
physician reviewer found although you remain morbidly obese with several obesity co-morbid conditions, poor 
dietary and lifestyle habits are recorded on multiple notes from the NP and RD without documentation of clear 
compliance and clearance documentation to support that you have followed through with all of the program 
requests (such as food logs, not eating out, weight loss, etc.). Given that there are no overt complications of the 
prior lap band, repeat bariatric surgery is not determined appropriate and medically necessary without 
documentation that you are felt to be a good candidate and have been compliant with program requirements. 
There is no nursing or dietary note reporting good candidacy of you for repeat bariatric surgery at this time. 
 
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 repeat bariatric surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the repeat bariatric surgery (CPT code 43775).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from 
July 27, 2021, to October 4, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you should not be 
charged for the operating room when you had an ultrasound. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
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 $100 
copayment for outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center 
for outpatient hospital services.  You have been asked to pay a total of $500 ($100 copayment x 5 visits = $500) for outpatient hospital services. 
Outpatient hospital services 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 outpatient hospital services provided from July 27, 2021, to October 
4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the specialist office 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 $30 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $30 copayment for the specialist office visit. Specialist 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 a specialist office visit provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara injections. 
 
You asked the Plan to pre-approve Stelara injections. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Stelara injections are not covered under the enrollee's 
Medicare Part B benefit. 
 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 Stelara injections.  
 
Benefits for Stelara injections 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided June 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the near-infrared spectroscopy studies rendered on 
September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had multiple ulcers to the left 
heel and received standard wound care and debridement. He was referred to vascular surgery.  There is no indication that he had other less-invasive testing to determine vascular status. The services were 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the near-infrared spectroscopy studies rendered on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. 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 acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no mention of chronic low back pain in the 
medical records and there is no order for acupuncture. Therefore, we decided that the Plan does not have to pre-
approve acupuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical artificial disc replacement. 
 
You asked the Plan to pre-approve a cervical artificial disc replacement. 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 follows Medicare rules. Medicare rules say that prosthetic cervical discs reasonable and necessary for 
the treatment of Medicare beneficiaries with symptomatic cervical degenerative disease or herniated disc at a 
single level when specific 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 a cervical artificial disc replacement. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found cervical disc 
replacement surgery above a previous fusion remains experimental. More research is needed to show safety 
and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cervical artificial disc replacement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a cervical artificial disc replacement.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arikayce suspension. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Arikayce suspension.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Dexcom Glucose monitoring system (A9277, A9276) 
provided January 19, 2021. 
 
You asked the Plan to pay for the Dexcom Glucose monitoring system. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this brand of glucose monitor is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The glucose monitor provided was not of the preferred brand and was 
not provided by an in-network vendor. Based on this information, we decided that Medicare rules for coverage 
of the Dexcom Glucose monitoring system have not been met. Therefore, we decided that the Plan does not 
have to pay for a Dexcom Glucose monitoring system (A9277, A9276) provided January 19, 2021.
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 the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee remains critically ill and requires ongoing acute critical care services. 
The enrollee continues to receive acute care services, and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for drug testing provided on September 29, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and the 
electrocardiogram (93005) rendered by the out-of-network (OON) provider on January 5, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the hospital outpatient clinic visit (G0463) and the electrocardiogram (93005) 
rendered by the out-of-network (OON) provider on January 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 60 additional routine transportation trips. You say that since being 
denied for additional transportation trips you have missed heart doctor, lung doctor and therapist appointments. 
You say that you have gained weight and your progress has stopped. You say that missing your appointments is 
life or death. The Plan denied your request. The Plan says your benefit for routine transportation trips has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way routine transportation trips per year.   
We looked at your request, the records in the case file, and the rules. The case file shows that you have 
received coverage for 60 one-way routine transportation trips in the 2022 calendar year. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve 60 additional routine 
transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Synthroid.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.