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

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the patient is currently enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the therapy as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve proton beam radiation therapy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee needs help right away due to 
their condition. The Plan denied your request. The Plan says home health care for assistance with activities of 
daily living, bathing, or household chores is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the garments for 
lymphedema and axillary web syndrome. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio test strips. 
 
You asked the Plan to pre-approve OneTouch Verio test strips. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says there is no medical reason this specific brand 
of test strip is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 OneTouch Verio test strips have been 
met. In this case, no medical records have been provided that indicate why the requested brand of test strips is 
medically necessary over the Plans preferred brand of test strips.  Therefore, we decided that the Plan does not 
have to pre-approve OneTouch Verio test strips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
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 30 trips per year.  
 We looked at your request, the records in the case file, and the rules. 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 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis; without contrast 
material (s) (72195). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that you have reported a clinical 
history suspicious for pelvic prolapse. Your symptoms are suspicious for rectal prolapse and the use of an MRI 
defecography could provide resolve to the diagnostic dilemma. Therefore, the requested service is 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the pelvis; without contrast material (s) (72195).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 17, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are on a fixed income and 
cannot afford this bill. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay $254.52 which is 20% of the allowed amount for an injection. The allowed amount 
is $1,272.60 (20% x $1,272.60= $254.52). Injections fall within the Medicare Part B Prescription Drugs 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 coinsurance for an injection provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on December 2, 
2021. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you met your out-of-pocket 
maximum already so it should be covered. 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 $15 
copayment for each Medicare covered exam.  
 
You have been asked to pay $15 copayment for an eye exam. Eye exams fall within the Vision 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 an eye exam provided on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI joint RFA. You say that ablation of the nerves has a good chance of 
alleviating pain. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this procedure is not supported by research and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational due to the wide variation in efficacy 
described in peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the MRIs provided on March 10, 2022, 
and April 15, 2022. 
 
You asked the Plan to waive the copayments for MRI's. You say that you shouldn't have had two MRI's done, 
if the doctor did it right the first time so it should be covered. The Plan denied your request. The Plan says the 
copayments applied 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 $200 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
 
 
 You have been asked to pay a total of $365.24 which is $182.62 for each MRI which is less than the standard 
$200 copayment for MRI's. 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 copayments for MRI provided on March 
10, 2022, and April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
on January 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you are on a fixed 
income with Social Security, and would like the Plan's decision to be reversed The Plan denied your request. 
The Plan says the copayment amount that you are 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). Your contract with the Plan clearly says that you must pay a $60 
copayment for out-of-network Vision care.  
 
 
 You have been asked to pay a $60 copayment for the outpatient office visit. This outpatient office visit falls 
within the out-of-network Vision 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 
the outpatient office visit (99213) provided on January 31, 2022 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay from February 19, 
2022, to March 20, 2022. 
 You asked the Plan to pay for the SNF stay. The Plan denied your request. The Plan says the enrollee was 
medically stable and did not require any skilled services. 
 
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 pay for the SNF stay. Our reviewer says that skilled 
nursing facility (SNF) care was not medically necessary. Our physician reviewer found that the enrollee did not 
have daily skilled nursing or therapy needs that required the specialized skill, knowledge, and judgment of a 
skilled professional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) stay from February 19, 2022, to March 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 21, 2020, to March 25, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you already paid $971.02 
so it should be all covered. 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 $325 
copayment per day for days 1 through 5.  
 
You have been asked to pay $1,300 ($325 x 4 days) copayment for inpatient hospital stay. 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 provided from March 21, 2020, to March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that this should be billed the same way as 
in 2021 with a coinsurance. 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 $390 
copayment per visit.  
 
You have been asked to pay $390 copayment for an injection. Injections 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 injection provided on April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 days of in hospital Ketamine infusions (J3490). 
 
You asked the Plan to pre-approve Ketamine infusions. You say that you are appealing the denial of a hospital 
stay for Ketamine infusions. The Plan denied your request. The Plan says Ketamine IV is considered 
investigational and experimental for treatment of migraine because there is insufficient evidence in peer- 
reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ketamine infusions have not been met. Therefore, we decided that the Plan does not have to pre-
approve 7 days of in hospital Ketamine infusions (J3490).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 28, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you never had to pay this much in 
the past. 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 $160 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
 
You have been asked to pay $160 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Treatment (G6002x35, 77523x35, 
77525x35). 
 
You asked the Plan to pre-approve Proton Beam Treatment. You say that the requested treatment is necessary. 
The Plan denied your request. The Plan says you are currently enrolled in a clinical trial. Once you sign a 
Medicare approved clinical trial consent form, original Medicare is responsible for routine cost associated with 
Medicare approved clinical trial services furnished to beneficiaries enrolled in managed care plans. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Proton Beam Treatment as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Proton Beam Treatment (G6002x35, 77523x35, 77525x35).