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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 20, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you went 
to the fire station because you were having palpitations. You also say that the ambulance did not provide any 
care, nor were you transported. The Plan denied your request. The Plan says this claim processed appropriately 
because you denied transportation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that your preference was to not be transported to the hospital by ambulance. Therefore, we 
decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) 
provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 27, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the attached medical records should be reviewed, 
and the claim reconsidered for payment. The Plan denied your request. The Plan says the provider must attempt 
to consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on October 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors. 
 
You asked the Plan to pre-approve CGM sensors. The Plan denied your request. The Plan says there is no 
documentation that your insulin treatment regimen requires frequent adjustments on the basis of Blood Glucose 
Testing or Continuous Glucose Monitoring. 
 
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 you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of CGM sensors have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) 
sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion visit with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve second opinion visit. You say that the Plan is not capable of meeting your 
needs because there is no one in the network with recognized specialization in your condition. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this provider is out-
of-network with the Plan and you can be treated by an in-network oncologist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 second opinion visit. Our reviewer says 
that you do not meet the Medicare criteria for care with the requested out-of-network provider. Our physician 
reviewer found your condition is diagnosed and managed by most medical oncologists. The current 
recommendations are for observation which is standard and several physicians have been offered for a second 
opinion. There is not anything unique about your condition that would make it medically necessary for you to 
see the requested out-of-network physician. The Plan has in-network physician who meet the standards of care 
required for treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of second opinion visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a second opinion visit with an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care for the enrollee is medically necessary. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs skilled therapy 
services 5 days a week. The enrollee can receive the care that they need in another setting like at home, in a 
long-term care facility, or other outpatient setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy on March 28, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being 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 $60 
copayment for Medicare-covered therapeutic radiology services. Covered services include but are not limited 
to other outpatient diagnostic tests.   
 
You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy 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 radiation therapy on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on April 1, 2022. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says that the 
medical records submitted indicate that the member had annual visit for both dates of service. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of denosumab (Xgeva). 
 You asked the Plan to pre-approve Xgeva. You say that this is part of a clinical trial and should be approved 
because the Plan is saving money by using the clinical trial for medication. The Plan denied your request. The 
Plan says this drug is part of a clinical trial in which the enrollee is enrolled; therefore, the Plan is not 
responsible for coverage of this drug. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Xgeva as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of denosumab (Xgeva).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) System (33289). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the device is medically necessary. 
The Plan denied your request. The Plan says this device has not been proven to improve the management of 
chronic heart failure (CHF) compared to standard monitoring. There has not been enough research done to 
prove that this device will improve your CHF treatment or reduce future problems that would require you to be 
hospitalized. The CardioMEMS HF System is considered investigational or experimental. 
 
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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. There 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary in your 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 a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) System (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that this treatment is medically necessary, and you will use 
ultrasound imaging to track the progress of treatment and adjust the course, if necessary. The Plan denied your 
request. The Plan says picture studies are not supported to guide the enrollee's type of treatment. The requested 
service remains denied due to lack of medical necessity for the request. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is a type of treatment that uses beams of intense energy to kill or shrink diseased cells. 
There is not sufficient evidence for the efficacy of image guided radiation therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT) (G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81404) provided January 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. This service was not ordered by the treating physician. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81404) provided January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis with contrast. You say that the 
requested service is medically necessary. The Plan denied your request. The Plan says a similar study has been 
approved, therefore the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis 
with contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found with 
significant renal insufficiency as this enrollee has, this study is unlikely to add any additional information. A 
renal ultrasound or magnetic resonance imaging (MRI) may be more useful. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen and pelvis with contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2022 billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 
81401, 81406, 81407, 81401, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 23, 2022 billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81238, 81240, 81241, 81291, 
81306, 81328, 81355, 81335, 81401, 81406, 81407, 81401, 0031U, 0032U, and 0033U.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124) visits. 
 
You asked the Plan to pre-approve the massage therapy visits. The Plan denied your request. The Plan says 
massage therapy is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy (97124) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 
6, 2021, to August 4, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the provider 
did not submit the RAP claim for services for date of service July 06, 2021, to August 4, 2021, until August 19, 
2021. This means the RAP was not submitted within five calendar days after the from date. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from July 6, 
2021, to August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 laboratory services provided on May 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have right 
sacroilitis. The requested RFA of the lateral sacral branches is considered experimental/investigational in 
nature due to wide variation in effectiveness reported in the medical literature. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick urine collection system. 
 
You asked the Plan to pre-approve a PureWick urine collection system. You say that this is supported in the 
records. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that female external urinary collection devices are 
covered for beneficiaries who have permanent urinary incontinence when used as an alternative to an 
indwelling catheter. 
 
We looked at the file and Medicare rules. The records show that this is not being requested as an alternative to 
an indwelling catheter. Based on this information, we decided that Medicare rules for coverage of a PureWick 
urine collection system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
PureWick urine collection system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided on January 28, 2022, to 
April 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pain management services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 pain management services provided on January 
28, 2022, to April 7, 2022, by an out-of-network (OON) provider.