Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin (J1815 x 2) provided in an outpatient setting from 
September 25, 2021, to September 26, 2021. 
 
 You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital waiting for 
your insurance. You say that you were not eating food. You say that you were not able to take your oral 
medications to control your blood sugar. You also say that the insulin was necessary. The Plan denied your 
request. The Plan says the drugs you received are considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs 
you received are not covered under Medicare Part B. 
 
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 pay for the insulin (J1815 x 2) provided 
in an outpatient setting from September 25, 2021, to September 26, 2021.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. You say that you would like reconsideration because 
the requested SI joint injection is medically necessary. The Plan denied your request. The Plan says physical 
exams from last two provider office visits do not note any positive pain reproduction, positive provocative 
testing on physical exam or ongoing active participation in a therapeutic exercise program. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of tenderness of the SI joint and 
no mention of SI provocative testing being completed with positive findings.  The clinical value and 
effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. In addition, there has been no trial of conservative 
therapy such as physical therapy or a home exercise program.  The review has determined that you do not have 
a diagnosis/condition that meets the criteria for the requested services. 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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99204) provided on June 4, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that prior authorization is not required for an 
office visit. The Plan denied your request. The Plan says the member does not have out of network benefits and 
the servicing provider is not a participating provider with the Plan. The Plan also says that these were 
unauthorized services 
 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 (99204) provided on June 
4, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablet 112mcg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
 
 
 
 
 
 
 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 Synthroid tablet 112mcg for 
the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayments for skin graft procedures provided from August 6, 2021, 
to November 24, 2021. 
 
You asked the Plan to waive the copayments for skin graft procedures. You say that you were unaware of the 
possible consequences of the radiation treatment due to your age. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount. 
 
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 a $0 copayment for minor procedures at an outpatient 
hospital.  
 
The Plan says you must pay a $245 copayment for skin graft procedures. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for minor procedures. The medical records show you 
had minor procedures from August 6, 2021, to November 24, 2021. Therefore, we decided that the Plan has to 
waive the copayments for skin graft procedures provided from August 6, 2021, to November 24, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you did not receive 
the services in a hospital facility and received them in a specialist's office. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $0 
copayment for advanced imaging services provided at a primary care physician's office, specialist's office or a 
stand-alone imaging center and a $200 copayment for advanced imaging services provided in an outpatient 
hospital facility.  
 
 The record shows that you received myocardial perfusion imaging at an outpatient hospital facility on 
November 1, 2021. Therefore, you are responsible to pay the $200 copayment.  
 
You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 myocardial perfusion imaging provided on November 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the facility should have obtained authorization and 
the services were provided so claim should be paid. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider with no referring provider. Also, the services provided were 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 an office visit provided on July 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invega Trinza for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
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 Invega Trinza for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs used for wound care on November 3, 
2021. 
 
You asked the Plan to pay for self-administered drugs. You say that the self-administered drugs at issue were a 
necessity for your care. The Plan denied your request. The Plan says rules for payment for self-administered 
drugs have not been met. 
 
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 pay for self-administered drugs used for 
wound care on November 3, 2021.   
Benefits for self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because there is little evidence in medical literature to suggest that Intracept is appropriate for the 
enrollee. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the injection(s), anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (64483) provided on August 10, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $400 
copayment for each Medicare-covered ambulatory surgical visit provided.  
 
 
 You have been asked to pay a $400 copayment for the Medicare-covered ambulatory surgical visit provided. 
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 adjust the copayment for the injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (64483) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 9, 2021. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says customers are 
required to contact the Plan's hearing vendor to access the routine hearing exam and supplemental hearing aid 
benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plans hearing vendor. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on  
July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), extraction (D7210), inhalation of 
nitrous oxide (D9230), root canal (D3330), periapical x-ray (D0220), limited oral evaluation (D0140), and 
filling (D2391) provided from June 21, 2021, to August 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that there were not in network providers in your 
area. You say that you were forced to go out of network. You say that The Plan denied your request. The Plan 
says the dental services you received are not covered. 
 
  Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), 
extraction (D7210), inhalation of nitrous oxide (D9230), root canal (D3330), periapical x-ray (D0220), limited 
oral evaluation (D0140), and filling (D2391) provided from June 21, 2021, to August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 26, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that services were provided to the enrollee so the 
claim should be paid. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers. Also, the services provided were 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 imaging services provided on February 26, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy with biopsy (45380) and a diagnostic 
esophagogastroduodenoscopy (43235) provided on April 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a colonoscopy with biopsy and a diagnostic esophagogastroduodenoscopy. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says the 
unauthorized services rendered were by a non-participating provider. The Plan also says that it was determined 
that the services received were not urgent/emergent, and the member does not have out of network coverage for 
services determined to be non-urgent/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 colonoscopy with biopsy (45380) and a 
diagnostic esophagogastroduodenoscopy (43235) provided on April 5, 2021, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on November 
17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this service was not urgent, emergent or 
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 the psychotherapy services (90837) provided on 
November 17, 2021 by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 
care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement silicone custom partial hand restorative 
passive device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is incorrectly coded. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request exceeds the enrollee's needs. The documentation does not reveal an objective physician 
physical examination of the right hand indicating a need for a custom silicone prosthesis. Additionally, the 
documentation does not reveal that the enrollee is unable to meet her functional needs with an L6020 simpler 
partial hand.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a replacement silicone custom partial hand restorative passive device for the enrollee.