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

 
We decided that the Plan does not have to pay for observation care services provided from April 8, 2022, to 
April 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the observation care. You say that the enrollee was kept after an ER visit, and the 
services should be paid. The Plan denied your request. The Plan says there are no out-of-network benefits for 
observation care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for observation care services provided from April 8, 
2022, to April 9, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic hearing service provided on 
April 11, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic hearing service. You say that you believe that a $0 
copay should be applied. The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for out-of-network Hearing services (Medicare covered). 
  
You have been asked to pay a $25 copayment for a diagnostic hearing service. This item/service falls within 
the out-of-network Hearing services (Medicare covered) 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 diagnostic hearing service provided on April 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9500 and S9501 billed for date of service 
February 23, 2022, to March 1, 2022. 
 
You asked the Plan to pay for procedure codes S9500 and S9501. You say that the codes are valid. The Plan 
denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes S9500 and S9501 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S9500 and S9501 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes S9500 and S9501 billed for date of service February 23, 2022, to 
March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection (0232T).

You asked the Plan to pre-approve PRP injection. You say that the enrollee has received PRP injections in the past. You say that the enrollee reports they have helped. You also say the enrollee does not want to have surgery. The Plan denied your request. The Plan says the PRP injection 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 PRP injection. Our reviewer says that the requested PRP injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence is insufficient to determine the effects of PRP on health outcomes for osteoarthritis. Therefore, the reviewer found that the the requested PRP injection is 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 PRP injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection (0232T).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183). 
 
You asked the Plan to pre-approve an MRI of the abdomen. The Plan denied your request. The Plan says that it 
was indicated that an MRI was not needed every 6 months. 
 
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 an MRI of the abdomen. Our reviewer 
says that an MRI of the abdomen is medically reasonable and necessary. Our physician reviewer found the 
elevated risk of Hepatocellular carcinoma (HCC) in patients with cirrhosis is well known and the imaging 
surveillance with ultrasound and MRI each at 6-month intervals is standard practice. Our reviewer found that 
an ultrasound is a valuable test, but the referring clinician is concerned about the accuracy of this test given the 
enrollee's obesity. Obesity can be a very limiting condition for an ultrasound and since the goal is early 
detection of HCC a good quality test is essential for HCC screening. Our physician reviewer also found that an 
MRI is not limited by obesity, so it is reasonable to rely on the hepatologist's opinion that yearly screening with 
ultrasound is not sufficient for this enrollee, and therefore, an MRI every 6 months instead of yearly is 
reasonable and indicated. 
 
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 MRI of the abdomen have not been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.

You asked the Plan to pre-approve Contour Next test strips. 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 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 as long as the enrollee retains access to all medically necessary items (including non-preferred brands).

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 Contour Next test strips. Our reviewer says that the services are not medically necessary. Our physician reviewer found that it is not explained why the enrollee needs this brand of test strips/meter instead of the preferred brand. Hence, medical criteria for coverage of the contour next strips are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Next test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oculoplastics consultation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON oculoplastics consultation. You say that this service is needed for 
eyelid surgery. The Plan denied your request. The Plan says these services are available from network 
providers. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an oculoplastics consultation to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a diagnostic colonoscopy provided on May 
18, 2022, to May 26, 2022. 
 
You asked the Plan to waive the cost share for a colonoscopy, office visit, and lab services. You say that you 
were told if there was polyp it would be $200. The Plan denied your request. The Plan says this cost sharing 
was charged 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 outpatient hospital services, including a colonoscopy. The contract also says that you must pay a $45 copayment for each physician/practitioner service, including a specialist office visit. The contract also says 
that you must pay a $15 copayment for Medicare-covered lab services.  
 
The record shows these claims were approved, and you are responsible for a cost share amount. You have been 
asked to pay a $300 copayment for a diagnostic colonoscopy on May 18, 2022. This item/service falls within 
the outpatient hospital services benefit category. 
 
You have been asked to pay a $45 copayment for a specialist office visit on May 26, 2022. This item/service 
falls within the physician services benefit category.  
 
You have also been asked to pay $5.18, which is less than the $15 copayment for a lab service on May 26, 
2022.  
 
You have also been asked to pay $2.25, which is less than the $15 copayment for a urinalysis on May 26, 2022.  
 
You have been asked to pay a total of $52.43 ($45 copayment + $5.18 copayment + $2.25 copayment = 
$52.43.) These items/services fall within the outpatient diagnostic testing 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 cost share for a diagnostic colonoscopy provided on May 18, 2022, to May 
26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you would like to appeal for an LTACH admission. The Plan denied your request. The Plan says the LTACH services you are requesting do not meet the requirements for approval.

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 does not require services that are not currently available at the acute care hospital where they are currently receiving care. The enrollee can remain at the current acute care hospital until such time no acute services are required. The enrollee can then be transferred to a lower level of care for any ongoing long term care needs.



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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
pralatrexate injection provided on December 27, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the specialist visit and injection. You say that 
you had met your out-of-pocket maximum. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $40 
copayment for physician/practitioner services, including doctor's office visits (specialist). Your contract also 
clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 
 You have been asked to pay a $40 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits (specialist) benefit category. You have also been 
asked to pay $95 for the injection, which is less than the 20 % coinsurance ($13,474.94 allowed amount x 20% 
= $2,694.99). This amount is less due to meeting your maximum out-of-pocket expenses on this claim. This 
item/service falls within the Medicare Part B prescription drugs benefit category. The total for all services is 
$135. 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 and coinsurance for a specialist office visit and 
pralatrexate injection provided on December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on July 4, 
2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on July 4, 2022.  
 Benefits for these items 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 pre-approve foot orthotics (L3030). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease. Additionally, you do not wear a shoe that is an 
integral part of a covered brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-
approve foot orthotics (L3030).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator (64561, 64581). 
 
You asked the Plan to pre-approve the sacral nerve stimulator. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator 
would be effective and a permanent implantation in appropriate candidates. 
 
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 sacral nerve stimulator. Our 
reviewer says that the requested stimulator is not medically necessary. Our physician reviewer found the 
records show the enrollee has new bladder cancer that has yet to be fully treated and could be contributing to 
the urinary symptoms. Until the bladder cancer is completely treated and resolved, the member cannot qualify 
for a sacral nerve stimulator device. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacral nerve stimulator (64561, 64581).
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 LTACH is the only place that can 
medically provide the services you need. The Plan denied your request. The Plan says admission to the LTACH 
did not meet the criteria, was not medically necessary and the enrollee can be discharged to a lower level of 
care. 
 
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 that the enrollee appears to be improved with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary 
as the enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is recommended. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services you need are too complex to 
manage at the current care facility. The Plan denied your request. The Plan says the criteria for LTACH 
admission were not met and the enrollee's medical needs are being met in the current acute setting. 
 
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 that the enrollee appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended. 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 LTACH services.