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

 
We decided that the Plan has to hold you harmless for the near infrared dual imaging provided on February 15, 
2022, billed with code 0507T. 
 
You asked the Plan to hold you harmless for the near infrared dual imaging. You say that this testing was 
necessary to determine the cause of your eye condition which was not resolved by other treatments. The Plan 
denied your request. The Plan says that this is considered an investigational procedure and is not covered by the 
Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the near infrared dual imaging by a contract provider. The file does not show that the 
Plan provided notice that the near infrared dual imaging would not be covered. Under Medicare rules, this 
means the near infrared dual imaging is considered approved by the Plan. Therefore, we decided that the Plan 
has to hold you harmless for the near infrared dual imaging provided on February 15, 2022, billed with code 
0507T.  
 
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 pre-approve radiofrequency ablation to the SI joint (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. The Plan denied your request. The 
Plan says radiofrequency ablation to the SI joint 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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested radiofrequency ablation to the SI joint not considered medically 
reasonable and necessary in this case. Our physician reviewer found that 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. Studies completed say that this procedure does 
not improve outcomes compared to standard treatment of SIJ pain. 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for observation services provided from 
February 5, 2022, to February 6, 2022. 
 
You asked the Plan to waive the copayment for the observation services. You say that you were under the 
impression that you had a small copay for a hospital stay. The Plan denied your request. The Plan says the 
copayment was 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 $300 
copayment for in-network Medicare-covered observation services.  
 
 
  You have only been asked to pay $245.27 for the observation services which is less than the standard $300 
copayment. The observation services fall within the Outpatient Hospital Observation 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 observation services provided from February 5, 2022, to 
February 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Calcitriol. 
 
You asked the Plan to pre-approve Calcitriol. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered 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 Calcitriol.  
 
Benefits for Calcitriol 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), endodontic therapy (D3330), 
and consultation (D9310) provided on February 15, 2022. 
 
You asked the Plan to pay for the pulp vitality tests, endodontic therapy, and consultation. You say that the 
provider and the Plan told you that you would be responsible for a $163.00 copayment for the root canal. You 
also say that you feel you should not be held responsible for this bill. The Plan denied your request. The Plan 
says these services are not covered expenses under your dental plan. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp 
vitality tests (D0460), endodontic therapy (D3330), and consultation (D9310) provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 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 billed correctly. 
 
 
 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 these 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 the laboratory services rendered on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic visit (G0463) provided on August 30, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the clinic visit. You say that please see attached medical records and reconsider 
claim for payment based on medical necessity without authorization. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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 outpatient clinic visit (G0463) provided on August 
30, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 15, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have been seeing this provider for 
many years. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 psychotherapy services provided on February 15, 2022 by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on March 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you went where your doctor sent you, and you 
were not told to ask if the hearing aids qualified for a rebate or to ask if they were supplied by the Plan's 
hearing aid vendor. The Plan denied your request. The Plan says hearing aids are to be supplied by the Plan's 
hearing aid vendor. 
 
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 hearing aids (V5261) provided on March 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) unit 
provided on March 21, 2022. 
 
You asked the Plan to pay for the TENS unit. You say that you feel that since the TENS unit is part of your 
treatment plan, and on the list from your physical therapist, that the Plan should allow an exception and cover 
it. The Plan denied your request. The Plan says a TENS unit is not a reimbursable item per the Pick Your Perks 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the TENS 
unit is an OTC item. However, the Plan offers a Pick Your Perks benefit that exceeds Medicare coverage. For 
that reason, the Plans coverage rules apply in this case. Therefore, we decided that the Plan does not have to 
pay for the transcutaneous electrical nerve stimulation (TENS) unit provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 11, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 83789 
is a column II code to column I code G0480. 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 services provided on August 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection does not meet 
the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, the epidural steroid injection performed on February 21, 2022 only provided pain relief for 2 weeks. 
There is no documentation indicating that the provider planned to use a different approach or medication for a 
failed response to that initial injection. The review has determined that the requested ESI does not meet the 
Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on January 14, 2022 to April 
14, 2022. 
 
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 are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on January 14, 2022 
to April 14, 2022.   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on March 2, 
2021.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 27, 2021, and 
December 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the facility used is the closest to the 
enrollee's address and you would like these claims paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 27, 
2021, and December 2, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the thoracic spine. We decided that the Plan does not 
have to pre-approve CT scans of the lumbar spine and the cervical spine. 
 
You asked the Plan to pre-approve the CT scans. You say that the CT scans are medically necessary. The Plan 
says that the CT scans are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered if there is literature to 
support its use for the patients condition and the scan is reasonable and necessary for the patient. 
 
We decided that the Plan has to pre-approve a CT scan of the thoracic spine. 
 
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 CT scan of the thoracic spine. Our reviewer says that the requested CT scan of the thoracic spine is considered medically reasonable and 
necessary in this case. Our physician reviewer found even though MRI exams were available for comparison 
from 2019, it is reasonable to pursue possible degenerative changes as a cause of chest wall pain in the thoracic 
spine in this enrollee with diffuse idiopathic skeletal hyperostosis (DISH), which is known to commonly 
involve the thoracic spine.  
 
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 CT scan of the thoracic spine have been met. Therefore, we decided that the 
Plan has to pre-approve a CT scan of the thoracic spine.  
 
We also decided that the Plan does not have to pre-approve CT scans of the lumbar spine and the 
cervical spine. 
 
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 CT scans of the lumbar spine and the 
cervical spine. Our reviewer says that the requested CT scans of the lumbar spine and the cervical spine are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical 
rationale to pursue possible discogenic pathology in the cervical or lumbar spine based upon the history of 
chest wall pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the lumbar spine and the cervical spine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve CT scans of the lumbar spine and the cervical 
spine. 
 
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 pay for an office visit provided on September 14, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 14, 2021, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.