Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hepatitis panel rendered on September 28, 2020. 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 testing is not covered. 
 
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 test at issue in this appeal, a hepatitis panel, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the hepatitis panel rendered on September 28, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for chemotherapy administration. We decided that the
Plan does not have to waive the copayment for a blood draw.
You asked the Plan to waive the copayment for chemotherapy administration and a blood draw. You say that
according to your benefits, you have no liability for chemotherapy drugs and related charges, including blood
draws. The Plan says that the copayment applied was correct.
We decided that the Plan has to waive the copayment for chemotherapy administration.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay $0 copayment for each Medicare-covered chemotherapy
drug to treat cancer and the administration of that drug.
The Plan says you must pay $20 copayment for each Medicare-covered chemotherapy drug to treat cancer and
the administration of that drug. Based on the Plan contract, however, you cannot be asked to pay more than $0
copayment for each Medicare-covered chemotherapy drug to treat cancer and the administration of that drug.
Therefore, we decided that the Plan has to waive the copayment for four chemotherapy administration services
provided from January 22, 2021, to March 25, 2021.
We also decided that the Plan does not have to waive the copayment for a blood draw.
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 $20
copayment for services obtained from an in-network specialist, or, under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office (as permitted under Medicare rules). An in-network specialist visit for a blood draw falls within the
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Therefore, we decided that
the Plan does not have to waive the copayment for a blood draw provided on February 8, 2021.
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 the supervision services rendered on March 27, 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 are not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99380 (supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the supervision services rendered on March 27, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Cardiac contractility modulation (CCM) system (0408T) for the enrollee.
You asked the Plan to pre-approve a CCM system. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that the clinical value and effectiveness of a Cardiac contractility modulation (CCM) system, in the setting of NYHA Class 1 heart failure has not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Our office requested additional information from the Plan because the case file was received with missing pages and incomplete. The Plan has not sent over the requested documentation. Therefore, we decided that the Plan has to pre-approve a Cardiac contractility modulation (CCM) system (0408T) for the enrollee.
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 a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553,
K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periapical additional radiographic image (D0230) provided 
on May 19, 2021. 
 
You asked the Plan to pay for a periapical additional radiographic image. You say that you disagree with the 
denial as you were told by the Plan that the provider was in-network. You also say you have stopped the deep 
cleaning until the situation is resolved with the Plan and the provider, as you do not have money to pay for all 
of this dental work. The Plan denied your request. The Plan says you are covered for one periapical x-ray once 
per calendar year and you have exhausted this benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and Medicare rules. The records show that you received a periapical radiographic image 
on May 19, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a periapical additional radiographic image have 
not been met. Therefore, we decided that the Plan does not have to pay for a periapical additional radiographic 
image (D0230) provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.

You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that you cannot maneuver in a regular twin size bed. The Plan denied your request. The Plan says that you do not meet coverage criteria for a heavy duty extra wide hospital bed.

The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 

We looked at the file and Medicare rules. The file indicates you do not weigh between 350 and 600 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan has to pay for a psychotherapy visit (90832) on November 20, 2020. 
 
You asked the Plan to pay for a psychotherapy visit. You say that the requested services were medically 
necessary for the enrollee. The Plan denied your request. The Plan says that rules for out of network care have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PPO plans must provide reimbur sement for all 
plan-covered medically necessary services received from non-contracted providers without prior authorization 
requirements.  
 
We looked at the file and Medicare rules. The Plan has not disputed the medical necessity of the services at 
issue. Based on this information, we decided that Medicare rules for coverage of a psychotherapy visit have 
been met. Therefore, we decided that the Plan has to pay for a psychotherapy visit (90832) on November 20, 
2020.  
 
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 oral nutritional formula (B4150).
You asked the Plan to pre-approve the oral nutritional formula. You say that the oral nutritional formula is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve oral nutritional formula (B4150).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physical therapy provided on January 22, 
2021 and January 25, 2021. 
 
You asked the Plan to waive the deductible for physical therapy. You say that he did nothing to help your wife 
who had pancreatic cancer. You say that you should not have to pay this. The Plan denied your request. The 
Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is your deductible is $750. This is the amount you have to pay out-of-
pocket before we will pay our share for your covered medical services. Until you have paid the deductible 
amount, you must pay the full cost of your covered services. 

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation 
services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$750 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received on January 22, 2021 to January 25, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided on 
January 22, 2021 and January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 8, 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 procedure codes 15734 and 17999 are not supported.

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, the CPT Code Manual definition of code 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. The definition of code 17999 is unlisted procedure, skin, mucous membrane and subcutaneous tissue. 

We find that CPT codes 15734 and 17999 (x2) are not supported in the medical record. Specifically, there is no documentation of a muscle, myocutaneous, or fasciocutaneous flap obtained from the trunk to support code 15734. There is no ocumentation of an unlisted procedure of the skin, mucous membrane and subcutaneous tissue to support code 17999. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the enrollee is limited to activity to a single 
room after post-operative hip replacement. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day reader.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says in order for this to be covered, there must be use of three or more insulin shots per day, or use of an insulin pump.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found you are injecting insulin once twice per day. There is a requirement that insulin be injected three times per day. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 day reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.

You asked the Plan to pre-approve facet injections. The Plan denied your request. The Plan says the injections are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injection are covered for the indications established in the applicable LCD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet injections. Our reviewer says that the requested facet injections are not medically reasonable and necessary. Our physician reviewer found that there is no documentation indicating that there has been a failure to respond to non-invasive/conservative care management and that there is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the enrollee's pain. The requested facet joint injections are not medically reasonable or necessary according to the coverage criteria established in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastroenterology office visit (99213) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the gastroenterology office visit. You say that the provider is close to your 
home and highly rated. You would like to use the out-of-network provider. The Plan denied your request. The 
Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
gastroenterology office visit (99213) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 22, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services rendered on February 26, 2021 to 
March 16, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the acupuncture was not 
performed for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay 
for the acupuncture services rendered on February 26, 2021 to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Methylprednisone Acetate injection 
you received on July 1, 2021. 
 
You asked the Plan to waive the coinsurance for the Methylprednisone Acetate injection. You say that you 
tried to pay this coinsurance at the doctor's office but they wouldn't let you.  You stated that you shouldn't have 
to pay this amount since they wouldn't accept it before. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 20% 
coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Methylprednisone Acetate injection. The 
Methylprednisone Acetate injection falls within the Medicare Part B drugs benefit category. This coinsurance 
applies regardless of whether or not the office accepted your payment when you tried to give it to them. 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 the Methylprednisone Acetate injection you received on 
July 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Thyrogen.
You asked the Plan to pre-approve a tier exception for Thyrogen. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Thyrogen have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Thyrogen.