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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an MRI of the lumbar spine have been 
met. Specifically, medical records were not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance 
imaging (MRI) of the lumbar spine (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2022 billed with 
codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661 
and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be considered a covered 
service as the diagnosis provided to order the test was not for preventative care and was in fact medically 
necessary to the treatment of such a diagnosis. The Plan denied your request. The Plan says claim does not 
meet Medicare requirements. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 20, 2022 billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 
87641, 87651, 87653, 87661 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a smaller power wheelchair. 
 
You asked the Plan to pre-approve a smaller power wheelchair. You say that the power wheelchair you 
currently have is not working for you. The Plan denied your request. The Plan says replacement of items is 
limited to situations involving loss or irreparable damage from a specific accident or natural disaster. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. Your current power wheelchair serves the same purpose as 
the requested smaller power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a 
smaller power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you need to see a specialist for your 
diabetes appointment. The Plan denied your request. The Plan says you are requesting an additional 88 miles 
for a total of 138 miles. The Plan also says that this request exceeds the benefit allowance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine without contrast. You say that the service is 
medically necessary. The Plan denied your request. The Plan says medical necessity cannot be determined 
without some form of records that addresses the enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of magnetic resonance imaging (MRI) of 
the cervical spine without contrast (72141). have been met. Specifically, the documentation does not include 
medical records. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging 
(MRI) of the cervical spine without contrast (72141).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you have an appointment scheduled, and 
cannot miss the appointment. The Plan denied your request. The Plan says the shortest mileage from your home 
to the office is a total of 54 miles, which is 4 miles over your allowed benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
26, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you are appealing with supporting records 
The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on June 27, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. 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 $90 
copayment for each emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on June 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on March 16, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. 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 $90 
copayment for emergency care. Cost-sharing is waived if you are admitted to the hospital within 24 hours. 
Emergency care refers to services that are furnished by a provider qualified to furnish emergency services and 
needed to evaluate or stabilize an emergency medical condition. 
 
 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and pay for outpatient surgery and self-
administered drugs provided on May 26, 2022. 
 
You asked the Plan to waive the copayment and pay for outpatient surgery and self-administered drugs. You 
say that you should not be charged for these drugs because the provider billed using general codes and not 
specific codes. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct. The Plan also says that the denial of payment for self-administered drugs is correct because these drugs 
are not covered by Medicare Part B. 
 
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 $250 
copayment for outpatient surgery at an outpatient hospital. The rules say that Medicare Part B generally does 
not pay for self-administered drugs. 
 
You have been asked to pay $250 copayment for outpatient surgery and self-administered drugs. outpatient 
surgery and self-administered drugs falls within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers 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. Additionally, 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 waive the copayment and pay for outpatient surgery and self-administered drugs provided on May 
26, 2022.  
 
Benefits for outpatient surgery and self-administered drugs 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 pre-approve six oncology/hematology office visits to be provided by 
an OON provider. 
 
You asked the Plan to pre-approve six oncology/hematology office visits. You say that you have received 
consistent care from this provider and you feel it's not in your best interest to switch to a new provider. The 
Plan denied your request. The Plan says the service is approved, but the provider is not as they are out-of-
network. There are numerous oncologists and radiologists within your network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
six oncology/hematology office visits to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara System for Oscillation and lung expansion 
(E1399, A9999). 
 
You asked the Plan to pre-approve the Volara System. You say that you are requesting review of the denial of 
coverage for the Volara System which was prescribed to help manage the enrollee's pulmonary exacerbations at 
home. The Plan denied your request. The Plan says medical studies have not proven this service/item is helpful 
for the treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Furthermore, the Plan indicates that on June 23, 2022 the Volara 
system was recalled for risk of respiratory distress in ventilated patients during home use. The FDA has 
identified this as a Class I recall, the most serious type of recall. Based on this information, we decided that 
Medicare rules for coverage of the Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Volara System for Oscillation and lung expansion (E1399, A9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a neurostimulator baroflex activation device 
(Barostim Neo). 
 
You asked the Plan to pre-approve Barostim Neo device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this device has no data showing a decrease in 
hospitalizations or reduction in mortality. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found to date, there are no mortality or hospitalization rate results available with this 
device. Although early trials of vagus nerve stimulation were positive, the largest and latest trial did not show a 
reduction in mortality and heart-failure hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a neurostimulator baroflex activation device (Barostim Neo).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin procedure provided on January 13, 
2022. 
 
You asked the Plan to waive the copayment for a skin procedure. You say that any other time you had this done 
it was a much cheaper copayment, and you're not sure why it is different now. The Plan denied your request. 
The Plan says the copayment that was applied was 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 
copayment for outpatient hospital services.  
 
You have been asked to pay a $180.19 copayment, rather than the full copayment amount of $300 for a skin 
procedure. A skin procedure falls 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 a skin procedure provided on January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor (CGM) 
supplies. 
 
You asked the Plan to pre-approve Dexcom G6 CGM supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested supplies are not a covered benefit. 
 
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. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom 
G6 continuous glucose monitor (CGM) supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need skilled nursing admission due to weakness 
and falls. The Plan denied your request. The Plan says based on Medicare guidelines, the skilled nursing 
services you are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are consistently ambulating more than 100 feet and tending to activities of daily 
living skills with minimal supervision. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. You do not have daily skilled nursing needs that require 
the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on June 05, 2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $325 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $325 copayment for ambulance. Ambulance falls within the Ambulance 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 ambulance on June 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you wish to see a pain specialist for years of 
chronic pain and not just back pain, and also for quality of life. The Plan denied your request. The Plan says 
care for your medical condition is available with in-network providers who can help assist with tapering down 
on chronic opiates and providing recommendations to 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 to be provided by an OON provider.