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

 
We decided that the Plan does not have to waive the copayment for the x-ray rendered on November 22, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this x-ray was part of your annual 
physical ordered by your primary care physician. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copay for Basic Radiological Services provided in an Outpatient Hospital.  
 You have been asked to pay $82.76 for the x-ray, which is less than the $90 copay. The x-ray 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 copayment for the x-ray rendered on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive audiometry threshold evaluation and 
speech recognition test (92557) and the tympanometry (impedance testing) (92567) rendered by the out-of-
network (OON) provider on October 11, 2021. 
 
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 comprehensive audiometry threshold evaluation and speech recognition test 
(92557) and the tympanometry (impedance testing) (92567) rendered by the out-of-network (OON) provider on 
October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections. 
 
You asked the Plan to pre-approve trigger point injections. The Plan denied your request. The Plan says 
conservative treatment has not been tried and failed and symptoms have not persisted for more than 3 months. 
 
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 trigger point injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no documentation of conservative treatment with pain medications, 
exercises or non-pharmacological modalities. In addition, the use of ultrasound guidance for trigger point 
injections is considered experimental and investigational because of insufficient evidence of its effectiveness. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trigger point injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger point injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eyelid cleanser. 
 
You asked the Plan to pre-approve these services. You say that your specialist stated the item would be 
beneficial for you. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an eyelid cleanser.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation for the watchman procedure to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation for the watchman procedure. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested 
service is of questionable medical necessity. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 consultation for the watchman procedure. Our reviewer says that there is 
no apparent contraindication to anticoagulation. As such, guidelines would not support implantation of a left 
atrial appendage closure (LAAC) in this setting. Our physician reviewer found there would appear to be no 
need to consult an out-of-network provider based on the evidence presented.  In summary, LAAC placement 
would not be considered reasonable or medically necessary in this enrollees clinical management. 
 
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 consultation for the watchman procedure have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the consultation for the watchman procedure. 
Therefore, we decided that the Plan does not have to pre-approve the consultation for the watchman procedure 
to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee should be qualified for this 
request. You also say that the enrollee needs a bed that can move up and down. The Plan denied your request. 
The Plan says this type of hospital bed is not covered by Medicare and therefore cannot be covered by the 
enrollees plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 Physical Therapy visits (PT), 2 Occupational Therapy 
(OT) visits, and 1 
MSW (Master of Social Work) visit. 
 
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration 
because the additional home health services are medically necessary. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for coverage of the additional home health services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the records do not show that skilled nursing or skilled therapy services are required to effectively 
provide treatment, care an/or services in order to improve your condition or to establish/perform a maintenance 
program to maintain your condition or prevent deterioration. Our physician reviewer found the requested MSW 
services are not medically reasonable and 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 Physical Therapy visits (PT), 2 Occupational Therapy (OT) visits, and 1 
MSW (Master of Social Work) visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (64625) provided on September 
15, 2021. 
 
You asked the Plan to pay for the radiofrequency ablation (64625). You say that the patient was seen for low 
back pain, and it was medically necessary to do the radiofrequency ablation due to the level of pain. You say 
that the charges should be reconsidered. The Plan denied your request. The Plan says radiofrequency ablation 
used for sacroiliac joint pain is considered not medically necessary/investigational whether performed using 
traditional, cooled, or pulsed radiofrequency. 
 
  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the radiofrequency ablation (64625). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that 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 
sacroiliac joint 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 the radiofrequency ablation (64625) have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiofrequency ablation (64625) provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services and computed 
tomography (CT) scan provided on September 29, 2021 to December 20, 2021. 
 
You asked the Plan to waive the copayment for emergency room services and CT scan. You say that these 
charges should be waived because your symptoms were covid related. The Plan denied your request. The Plan 
says the copayment amount 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 $90 
copayment for each emergency care visit, and a $150 copayment for each advanced imaging service. 
 
You have been asked to pay a total of $240 for emergency room services and CT scan. Emergency room 
services fall within the Emergency Care benefit category. CT scans 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 emergency room services and computed tomography (CT) scan provided on September 29, 2021 to 
December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary and rest home visit (99334) and the debridement 
of nails (11721) provided on November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary and rest home visit and the debridement of nails. You say that the 
services on this claim that were denied are not part of any other services performed on this date or on any other 
date and should be considered separate and distinct services. 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 domiciliary and rest home visit (99334) and the 
debridement of nails (11721) provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on October 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you would like the Plan to reconsider 
payment of this claim. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers and there was no 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 a specialist office visit provided on October 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) additional non-emergent routine 
transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
for future appointments. You say you have appointments for physical therapy and mental health. You are also 
having difficulty walking. The Plan denied your request. The Plan says additional trips would exceed your 
benefit limit. 
 
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 24 one-way trips per year.  We looked at your request, the records in the case file, and the rules. The records show that you have used 
eighteen (18) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 
24 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve twenty-four (24) additional non-emergent routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacral lateral branch 
nerves. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacral lateral branch nerves. You say that the 
requested radiofrequency ablation of the sacral lateral branch nerves is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested radiofrequency ablation of the 
sacral lateral branch nerves. 
 
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 of the sacral 
lateral branch nerves. Our reviewer says that the enrollee does not meet criteria for the requested 
radiofrequency ablation of the sacral lateral branch nerves. Our physician reviewer found the enrollee has 
bilateral sacroiliitis. He had bilateral diagnostic lateral sacral branch blocks on January 24, 2022, and February 
28, 2022, and achieved 80% pain relief for 1-2 weeks each time. Radiofrequency ablation of the sacral lateral 
branch nerves is considered experimental/investigational because of the wide variation in efficacy in peer 
reviewed literature.  Therefore, the request is deemed 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 radiofrequency ablation of the sacral lateral branch nerves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacral lateral 
branch nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection. 
  You asked the Plan to pre-approve the epidural steroid injection.. The Plan denied your request. The Plan says 
a repeat injection would only be approved if your pain improved by 50% for at least 3 months but it has not 
been 3 months since your last injection. 
 
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 epidural steroid injection. Our 
reviewer says that the review has determined that the enrollee does not meet the coverage criteria detailed in 
the LCD. Our physician reviewer found that a repeat injection is only indicated when the first injection directly 
and significantly provided improvement of the condition being treated. If an enrollee fails to respond well to 
the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level, and/or 
medication if appropriate, with the rationale and medical necessity for the second ESI documented in the 
medical record. A different approach or level was not documented 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 epidural steroid injection. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental 
pneumatic appliance (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that a basic pump 
has been ruled out as it is unable to address the enrollee's truncal swelling and would not be tolerated due to 
current pain levels. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for 
an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device 
of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) segmental pneumatic appliance (E0667, E0656).