Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic radiology procedures of the lower extremities (73721), 
magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says that a repeat right knee MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that an MRI 
is medically necessary Our physician reviewer found that the previous MRI was over 5 months ago. In that 
period of time there would be no expected change in the documented tear; however, ancillary findings 
including muscle atrophy or additional tears, or healing fractures could become apparent which if present 
would change the surgical approach. The request for a repeat MRI prior to possible surgery 5 months later is 
reasonable, and should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
diagnostic radiology procedures of the lower extremities (73721), magnetic resonance imaging (MRI).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for speech therapy services provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the speech therapy. You say that you did not have speech 
therapy done. You say that you only had something removed from your throat and had a swallowing test. The 
Plan denied your request. The Plan says 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physical, speech, or occupational therapy services.  
 
The file shows that the fluoroscopy procedure included speech therapy services. Therefore, you have been 
asked to pay a $20 copayment for the speech therapy. the speech therapy falls within the Outpatient Rehabilitation Therapy 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 speech 
therapy services provided on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from November 
6, 2021, to November 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you shouldn't be held 
liable for the copay because the surgery was the result of an infection from your previous surgery. The Plan 
denied your request. The Plan says the copayment applied 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 $300 
copay per day for the first five days for each medically necessary covered inpatient stay.  
 
 You have been asked to pay a $1,500 copay ($300 x 5 days) for the inpatient hospital stay. The inpatient 
hospital stay falls 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 the inpatient hospital stay from November 6, 2021, to November 11, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality-of-care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality-of-care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81348) rendered by the out-of-
network (OON) provider on August 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, 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 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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81348) rendered by the out-of-network (OON) provider on 
August 30, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging (CPT 78815). 
 
You asked the Plan to pre-approve a PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging. You say that a PET with concurrently acquired CT for attenuation correction 
and anatomical localization imaging is medically necessary. The Plan denied your request. The Plan says that a 
PET with concurrently acquired CT for attenuation correction and anatomical localization imaging is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET with concurrently acquired CT 
for attenuation correction and anatomical localization imaging. Our reviewer says that a PET with concurrently 
acquired CT for attenuation correction and anatomical localization imaging is medically necessary. Our 
physician reviewer found that the enrollee has metastatic disease now on both sides of the diaphragm. A 
PET/CT is the most reasonable and accurate method with which to stage this enrollee with a tumor showing 
diffuse metastatic features. 
 
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 PET with concurrently acquired CT for attenuation correction and anatomical 
localization imaging have been met. Therefore, we decided that the Plan has to pre-approve a positron emission 
tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and 
anatomical localization imaging (CPT 78815).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging (CPT 78815). 
 
You asked the Plan to pre-approve a PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging (CPT 78815). You say that a PET with concurrently acquired CT for 
attenuation correction and anatomical localization imaging is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET with concurrently acquired CT 
for attenuation correction and anatomical localization imaging (CPT 78815). Our reviewer says that a PET with 
concurrently acquired CT for attenuation correction and anatomical localization imaging is medically 
necessary. Our physician reviewer found the enrollee has a history of aggressive facial tumor and 
reconstruction. As such anatomical structures will be extremely if not impossible to differentiate from scar or 
tumor without the advantage of the metabolic activity associated with tumor. This differentiation would not be 
possible with routine MRI or CT thus PET/CT would be the best test to evaluate for residual/recurrent tumor. 
 
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 PET with concurrently acquired CT for attenuation correction and anatomical 
localization imaging (CPT 78815) have been met. Therefore, we decided that the Plan has to pre-approve a 
positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation 
correction and anatomical localization imaging (CPT 78815).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Part B Drugs and 
outpatient hospital services on October 14, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for Part B Drugs and outpatient hospital services. 
You say that you would like to request reconsideration of applied cost share. The Plan denied your request. The 
Plan says the cost share 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 $250 
copayment, 20% coinsurance for Part B Drugs and outpatient hospital services. The allowed amount of the Part 
B Drugs is $64.15, resulting in a coinsurance amount of $12.83. The allowed amount for the copayment of the 
outpatient hospital services is $166.60, resulting in the total cost-sharing amount $179.43. You have been asked to pay a $250 copayment for outpatient hospital services.  Outpatient hospital services 
fall within the outpatient hospital services benefit category. 
 
You have been asked to pay a 20% coinsurance for Part B Drugs. Part B Drugs fall within the Medicare Part B 
prescription drugs 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 and coinsurance for Part B Drugs and outpatient hospital 
services on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Injections on March 24, 
2021 to September 27, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for Injections. You say that you believe there is a 
mistake in the billing and that you are being overcharged. The Plan denied your request. The Plan says the cost 
share applied 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, 20% coinsurance for Injections. The total allowed amount of the injections is $756.48, resulting in 
a coinsurance amount of $151.30.  
 
The two $50 copayments are a separate charge according to Chapter 4 on page 114. of the Plan's 2021 
Evidence of Coverage (EOC). 
 
 You have been asked to pay a $50 copayment, 20% coinsurance for Injections. Injections fall within the 
Medicare Part B prescription drugs 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 and 
coinsurance for Injections on March 24, 2021 to September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive metabolic panel provided on September 2, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Comprehensive metabolic panel. You say that you would like to appeal 
reconsideration of payment for Comprehensive metabolic panel services that you received. The Plan denied 
your request. The Plan says the provider is not a network provider, and the services were not referred by a 
network provider. 
 
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 Comprehensive metabolic panel provided on 
September 2, 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 transitional care management services (99496) provided on 
August 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transitional care management services. You say that the patient was in a nursing 
home setting at the time services were rendered, and the patient could not choose an in-network internal 
medicine as they do not provide services in the patient's place of residence. You also say that since your 
company has an exclusive contract with the facility, your doctors are the only providers who will treat the 
patients for internal medicine care. The Plan denied your request. The Plan says an authorization was not 
obtained prior to the services being rendered. The Plan also says that the provider is not participating with the 
member's Plan, and the services rendered were not Plan Directed Care. 
 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 transitional care management services (99496) 
provided on August 27, 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 an office visit (99214) provided on December 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this is not a network 
provider with the Plan and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they 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 an office visit (99214) provided on December 13, 
2021, 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 Ultrasound on September 22, 2021. 
 
You asked the Plan to waive the copayment for an Ultrasound. You say that you do not agree with the 
copayment amount assessed. The Plan denied your request. The Plan says the copayment 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 $25 
copayment for an Ultrasound.  
 
You have been asked to pay a $25 copayment for an Ultrasound. An Ultrasound 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 an Ultrasound on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve PNS. You say that PNS is medically necessary. The Plan denied your 
request. The Plan says the Plan Medical Policy guidelines consider these types of systems unproven and not 
medically necessary. Functional electrical stimulation is only medically necessary for members with lower 
limb paralysis due to spinal cord injury with other criteria. Evidence is lacking. Large well-designed studies in 
the peer review scientific literature comparing stand-alone use of Reactiv8 device to established treatments are 
needed. Published studies do not demonstrate any long- term health outcome advantage with the use of 
Reactiv8 as an alternative treatment. 
 
The Plan follows Medicare rules. 
 
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 PNS. Our reviewer says that PNS is not 
medically necessary. Our physician reviewer found Medicare only covers implanted PNS and this request is for 
percutaneous PNS. Also, the Reactriv8 neurostimulator does not currently have high quality studies showing 
significant long-term benefit with its use in the setting of chronic spinal pain. Therefore, it does not meet the 
NCD coverage criteria based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve peripheral nerve stimulation (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the biopsy of a nail unit (11755) 
rendered by the out-of-network (OON) provider on August 12, 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 the services were rendered by an out of 
network provider, 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 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99204) and the biopsy of a nail unit (11755) rendered by the out-
of-network (OON) provider on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Inpatient Hospital stay on October 22, 
2021 to October 25, 2021. 
 
You asked the Plan to waive the coinsurance for an Inpatient Hospital stay. You say that that you don't feel you 
should have to pay that much for a weekend visit. The Plan denied your request. The Plan says the 20% 
coinsurance 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 20% 
coinsurance for an Inpatient Hospital stay. The allowed amount of the Inpatient Hospital stay is $10,909.60, 
resulting in a coinsurance amount of $2,181.92. 
 
 You have been asked to pay 20% coinsurance for an Inpatient Hospital stay. An Inpatient Hospital stay falls 
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 coinsurance for 
an Inpatient Hospital stay on October 22, 2021 to October 25, 2021.