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

 
We decided that the Plan does not have to pay for physician's services provided from January 20, 2022, through 
January 21, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Hospice is 
the primary payer at the time of these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on January 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided from January 20, 2022, through January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening you had on October 13, 2021. 
 
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says the benefit limit has 
been reached. 
 
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 one prostate cancer screening every 12 months.  
 
Review of the file shows that you had a prostate cancer screening on October 13, 2021. The records also show 
that you had a covered prostate cancer screening on December 8, 2020. This service is only covered once every 
12 months. The requested screening exceeds the benefit limit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay 
for the prostate cancer screening you had on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
December 9, 2021 and December 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as auxiliary 
personnel furnishing acupuncture must be under the appropriate level of supervision. 
 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, the Plan offers coverage beyond the Medicare acupuncture benefit.   
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services provided have not been met. Specifically, you did not provide the acupuncture 
treatment under the supervision of a physician, physicians assistant, or nurse practitioner/clinical nursing 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 
97811) provided on December 9, 2021 and December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on September 24, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. 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 domiciliary services provided on September 24, 
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 a domiciliary or rest home visit (99335) provided on January 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services should be covered as 
you disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they were non-emergent and prior 
authorization was not obtained. 
 
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 domiciliary or rest home visit (99335) provided 
on January 25, 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 cost-sharing for onabotulinumtoxina injection and chemo 
denervation of neck muscle (J0585, 64616) provided on January 6, 2022. 
 
You asked the Plan to waive the cost-sharing for the onabotulinumtoxina injection and chemo denervation of 
neck muscle. You say that the services should be covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 20% 
coinsurance for Medicare Part B prescription drugs and a $45 copayment for Physician/Practitioner services, 
including doctors office visits. 
 You have been asked to pay a 20% coinsurance for the onabotulinumtoxina injection (allowed is $618.50 x 
20% = $123.70), and a $45 copayment for the chemo denervation of neck muscles. 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-sharing for onabotulinumtoxina injection and chemo denervation of neck muscle (J0585, 
64616) provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS). 
 
You asked the Plan to pre-approve percutaneous electrical nerve stimulation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 percutaneous electrical nerve 
stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee takes 
a non-steroidal anti-inflammatory drug and Tylenol for pain. The enrollee has tried physical therapy. Imaging 
shows L3-L4 and L4-L5 spondylosis and forminal narrowing from L2-L3 to L4-L5. The requested service is 
considered experimental/ investigational at this point. Therefore, the enrollee does not meet 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 percutaneous electrical nerve stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye injection (67028) provided on 
January 26, 2022. and March 2, 2022. 
 
You asked the Plan to waive the copayment for the eye injection. You say that the services should be covered 
as you disagree with the charges, and they would cause financial hardship. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services 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 $100 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $200 copayment for two eye injections. Eye injection fall within the Outpatient 
hospital services 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 an eye injection 
(67028) provided on January 26, 2022. and March 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Premarin cream. 
 
You asked the Plan to pre-approve Premarin. You say that this medication is necessary for mucosal 
conditioning. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part 
B benefit. 
 
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 Premarin cream.  
 
 Benefits for Premarin 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 pay for the telehealth service provided on March 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth service. You say that due to the ongoing crisis, you had less staff 
and unable to obtain authorization.  The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 did not pre-approve the 
telehealth service. We found no exception that would require the Plan to pay for the telehealth service. The 
records provided for review do not show that telehealth service was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the telehealth service provided on March 10, 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 an outpatient office visit on February 22, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient office visit. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the cost share applied is 
correct. The member has a $233 combined deductible amount that has to be met before we pay the full cost of 
Part B services from in-network or out-of-network providers. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $233 deductible for an outpatient office visit.  
 
The enrollee has been asked to pay a $233 deductible for an outpatient office visit. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an outpatient office visit on February 22, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health services or at home with outpatient 
therapy. 
 
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 that while the enrollee may benefit from continued physical therapy and occupational 
therapy, her rehab needs can be safely provided in a lower intensity and alternate setting such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion interspinous device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Vertiflex Superion interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has tried conservative treatment that included epidural 
injections, medications, and physical therapy. Current evidence based medical guideline and peer reviewed 
literature do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for 
Vertiflex Superion interspinous device at L2-3 and L4-5 is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
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 a Group 2 PWC is covered when specific criteria 
are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the enrollee is able to ambulate short 
distances and has full motor strength in all extremities. He is limited in propelling a manual wheelchair due to 
pain. He is documented as able to ambulate household distances with no significant limitation to performing 
mobility-related activities of daily living within the home. He is noted to have gait instability but there is no 
indication that this cannot be resolved with the use of a walker within the home. The requested PWC is for 
longer distances, including community mobility. The criteria for coverage are not met and 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 a Group 2 power wheelchair (PWC).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on May 29, 
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 physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that a physician in the same specialist group billed 
another ER visit for the same date of service at issue. The services are therefore not separately payable. 
Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on 
May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a epidural steroid injection. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered for 
certain indications. 
 
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 epidural steroid injection. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee underwent a lumbar epidural injection at L5-S1 on May 
26, 2022. There is no documentation of the degree of pain relief from the epidural steroid injection performed 
on May 26, 2022. Therefore, the enrollee does not meet 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 a epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurostimulator insertion. 
 
You asked the Plan to pre-approve neurostimulator insertion. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 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 neurostimulator insertion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were being treated for chronic pain. You had the removal of a spinal cord 
stimulator on November 7, 2020. detailed documentation is not evident regarding a diagnosis of complex 
regional pain syndrome. There are no objective findings that would corroborate that diagnosis. Moreover, 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested neurostimulation in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
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 neurostimulator insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neurostimulator insertion.