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

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you need these services. The Plan denied 
your request. The Plan says services provided by an out-of-network provider are not covered without prior 
authorization. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for outpatient surgery services 
provided on March 9, 2022. 
 
You asked the Plan to waive the deductible and copayment for outpatient surgery services. You say that you've 
had the same procedure done before and you didn't have to pay this much towards a bill. The Plan denied your 
request. The Plan says the deductible and copayment was 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 clearly says that there is $750 deductible which applies to outpatient surgery. Your 
contract with the Plan also says that there is a $295 copayment for outpatient surgery after your $750 plan 
deductible is met.  
 
 
  The item or service you asked the Plan to waive the deductible and copayment for falls within the Outpatient 
Surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had 
not been met at the time the epidural injection claim was processed. 
 
In addition to your deductible, you have been asked to pay a $177.23 copayment for the epidural steroid 
injection. This means that you have been asked to pay less than your contracted cost sharing amount. 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 deductible and copayment for outpatient surgery services provided on 
March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided on 
. 
 
You asked the Plan to pay for the LTACH services. You say that with the enrollee's need for increased 
respiratory monitoring and the need of daily physician involvement, she has been referred to LTACH with an 
interdisciplinary treatment team approach. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and does not require transfer to a long-term facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the LTACH services. Our reviewer says that 
the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical record does not indicate that the enrollee requires services that she is not currently 
receiving, but that would be available at the LTACH facility. Our physician reviewer also found that the 
elements of the coverage rules are not satisfied. Our physician reviewer also found that the requested service 
cannot be recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services provided on .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal 
disease (ESRD) provided on January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 16, 2021, through November 24, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are being double 
billed. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $298 
copayment per day for days 1-7, and a $0 copayment per day for days 8-90 for inpatient hospital care.  
 
You have been asked to pay a $2,086 ($298 x 7 = $2086) copayment for inpatient hospital care. The services at 
issue fall within the inpatient hospital care 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 inpatient hospital care provided from November 16, 2021, through November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220), limited oral evaluation (D0140), 
endodontic therapy (D3330), and pulp vitality test (D0460) provided on April 5, 2022. 
 
You asked the Plan to pay for an intraoral x-ray (D0220), limited oral evaluation (D0140), endodontic therapy 
(D3330), and pulp vitality test (D0460). You say that you were in serious pain and the endodontists that were 
listed as in-network were either no longer in-network or had no openings in a reasonable time. The Plan denied 
your request. The Plan says their records indicate the dental provider is not active in the provider network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received from an out-
of-network provider are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for an intraoral x-ray (D0220), limited oral evaluation (D0140), endodontic therapy (D3330), 
and pulp vitality test (D0460) provided on April 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 30, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient Rehabilitation 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 physical 
therapy provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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 a FreeStyle Libre 2 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing. 
 You asked the Plan to pre-approve BRCA testing. You say that you are in dire need of knowing the medical 
history of cancer with this testing. The Plan denied your request. The Plan says the requested testing is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BRCA testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a family history of lung and breast cancer. The documentation indicates that you have 
no personal history of breast, ovarian, or pancreatic cancer. There is no documentation of any signs or 
symptoms of cancer. Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary 
peritoneal, pancreatic, or prostate cancer is not covered. Therefore, you do not meet criteria for the requested 
testing. 
 
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L36163 to support their 
denial. However, LCD L36163 is retired. Therefore, we cannot use LCD L36163 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that your primary care physician refused to see 
you because there were too many walk ins that day. You also say that this should be covered. The Plan denied 
your request. The Plan says the services you received out-of-network are not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan confirmed that the provider in this 
case did not refuse you on the date of service in this case but advised there would be a long wait. 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 office visit provided on January 
31, 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 an office visit 
 
You asked the Plan to pre-approve an office visit. You say that a regular dermatologist would not be able to 
perform the proper services. The Plan denied your request. The Plan says if you need specialty care, and we do 
not have a provider available in-network, we will make arrangements for you to receive care from an out-of-
network provider. You were provided with three in-network options to discuss with your primary care 
physician. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on 
February 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care (99309) provided 
on February 24, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee underwent coronary artery bypass surgery and has had a complicated 
postoperative course including ischemic bowel and acute respiratory failure. The record indicates that the 
enrollee still requires acute critical care services. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office 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 an office visit provided on March 11, 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 office visit on March 23, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $50 
copayment for each Medicare-covered exam to diagnose and treat diseases and conditions of the eye. Covered 
services include outpatient physician services for the diagnosis and treatment of diseases and injuries of the 
eye, including treatment for age-related macular degeneration. Original Medicare doesnt cover routine eye 
exams (eye refractions) for eyeglasses/contacts. 
 
You have been asked to pay a $50 copayment for office visit. Office visits fall within the Vision care 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 office visit on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
criteria have 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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe 
and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).