Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary to treat 
the enrollee's knee pain. The Plan denied your request. The Plan says that studies have not clearly shown 
genicular artery embolization being better than other treatments for severe osteoarthritis. 
 
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 requested services are not considered medically reasonable and necessary in this case. This procedure is 
experimental for extremity osteoarthritis treatment. More research is needed. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular artery embolization for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a physical exam provided on May 3, 2022. 
 
You asked the Plan to waive the coinsurance for a physical exam. You say that the Plan representative assured 
you that this service was in-network. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 40% 
coinsurance for out-of-network Provider and Professional Services. The allowed amount of this service is 
$141.76 resulting in a $56.70 coinsurance ($141.76 x 40% = $56.70). 
 
You have been asked to pay a $56.70 coinsurance for a physical exam. A physical exam falls within the out-of-
network Physician/Practitioner Services, Including Doctor's Office Visits 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 a physical exam provided on May 3, 2022.  
 Your complaint about customer service giving you incorrect information is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on May 24, 
2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that it was not your fault that you 
had to come back twice for a follow-up. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist visit provided on May 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 1, 2022, to January 25, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for 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 or skilled therapy needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pay for skilled nursing facility (SNF) services provided to the enrollee from January 1, 2022, to January 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided from August 
25, 2021, to August 26, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injures patient, first 30-74 minutes. 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
does not include a critical care progress note for the billed dates of service. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the critical care services coded 99291 provided from August 25, 2021, to 
August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) (0398T). 
 
You asked the Plan to pre-approve an MRgFUS. The Plan denied your request. The Plan says this service is not 
medically necessary. 
 
 
 The Plan follows Medicare rules. Medicare rules say that an MRgFUS unilateral thalamotomy is considered 
medically reasonable and necessary in patients who meet the criteria listed in the Medicare rules section of this 
letter. 
 
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 MRgFUS. Our reviewer says that the 
criteria for coverage for an MRgFUS have not been met. Our physician reviewer found you do not have an 
essential tremor or tremor-dominant Parkinsons disease. Our reviewer also found that you do not have 
moderate to severe postural or intention tremor of the dominant hand, a disabling tremor, and may be a surgical 
candidate for deep-brain stimulation. 
 
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 MRgFUS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image-guided radiation therapy (US-IGRT.) 
 
 
You asked the Plan to pre-approve US-IGRT. You say that your providers need to see the depth of the cancer. 
You say that the requested treatment is needed to be done so that your providers can see how much radiation 
treatment to give. The Plan denied your request. The Plan says US-IGRT is not medically necessary for 
superficial radiation therapy. 
 
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 US-IGRT. Our reviewer says that US-
IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found using 
ultrasound on a daily basis is not unreasonable to offer, but not necessary. Therefore, to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines is not necessary. Daily US-IGRT would not be furnished in accordance with 
accepted standards of medical practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound image-guided radiation therapy (US-IGRT.)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from July 1, 2021, to  
July 28, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says Medicare 
does not cover services with a Marriage and Family Therapist. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from  
July 1, 2021, to July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device services provided on 
January 31, 2022. 
 You asked the Plan to pay for the services provided. You say that the pneumatic compression device was 
prescribed to prevent the formation of blood clots. The Plan denied your request. The Plan says the items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. A PCD for the purpose of prevention of venous thromboembolism is a 
preventive service. Items that are used for a preventative service or function are excluded from coverage under 
the Medicare DME benefit. Furthermore, the device was provided for services at an ambulatory surgical center. 
The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers. This service was provided via arrangement of the facility. Payment for this 
service would have been included under the facility claim. Payment to you for this service is the responsibility 
of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression 
device services provided on January 31, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the knee surgery received from September 2, 2020, to September 3, 
2020. 
 
You asked the Plan to pay for the knee surgery. You say that you feel this service should be paid. The Plan 
denied your request. The Plan says that this service was previously processed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan is denying this service due to the claim 
already being processed. The documentation submitted does not include any information stating that this 
service was already paid and/or processed by the Plan. The Plan documentation states that the maximum out of 
pocket expenses that you have to pay is $10,000. You submitted documentation supporting a total of 
$23,756.77. The submitted documentation did not include rationale as to why the remainder was not 
reimbursed to you. The Plan documentation is missing required documentation to support the denial made. 
Therefore, the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the knee 
surgery received from September 2, 2020, to September 3, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a 
planned right total knee arthroplasty. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the CMS Inpatient Only List. The 
procedure is currently approved as an ambulatory procedure. There is no documentation provided to support 
the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your 
condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the 
upper extremity (73221). 
 
You asked the Plan to pre-approve an MRI of any joint of the upper extremity. You say that the enrollee has 
ongoing pain and swelling of the right elbow, and a further evaluation with an MRI of the right elbow is 
needed. The Plan denied your request. The Plan says this test 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 of any joint of the upper 
extremity. Our reviewer says that an MRI of any joint of the upper extremity is not reasonable and necessary. 
Our physician reviewer found per the reviewed documentation, there is a negative x-ray of all joints. The exam 
from July 7, 2022 notes the area is cool without erythema, synovitis, or effusion. Our reviewer found that the 
enrollee has a full, non-painful, range of motion through bilateral upper extremities. There are no objective 
findings to support failure of conservative management. Our physician reviewer also found that the requested 
MRI 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 an MRI of any joint of the upper extremity have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the 
upper extremity (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits December 27, 2021, 
to January 24, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you should not be 
responsible to pay these copayments because no visits occurred on these dates. 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 each specialist visit for Medicare-covered benefits, including telehealth services.  
 
You have been asked to pay $40 ($20/visit x 2 visits) for specialist office visits. Specialist office visits fall 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. Records 
submitted support services were rendered on these dates. 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 copayments 
for specialist office visits December 27, 2021, to January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair ramp provided on March 10, 2021. 
 
You asked the Plan to pay for the wheelchair ramp. You say that you were told it would be covered. The Plan 
denied your request. The Plan says the item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the wheelchair ramp provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have waive the deductible for eyelid surgery performed on January 5, 2022. 
 
You asked the Plan waive the deductible for eyelid surgery. You say that you were told there was no 
deductible. The Plan denied your request. The Plan says the deductible 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 says that there is a $1000 deductible which applies to eyelid surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been 
met at the time eyelid surgery was received on January 5, 2022. Therefore, we decided that the Plan does not 
have waive the deductible for eyelid surgery performed on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you had no idea you had such a large 
copayment, and you were told this would be covered by the Plan. The Plan denied your request. The Plan says 
you were charged this cost sharing 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 $195 
copayment for other diagnostic and nuclear medicine radiological services.  
 
You are being charged $129.10 rather than the full copayment amount of $195 for a CT scan. A CT scan 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 a computed tomography (CT) scan provided on March 9, 2022.