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

 
We decided that the Plan does not have to pre-approve a breast reduction. 
 
You asked the Plan to pre-approve a breast reduction. 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 follows Medicare rules. Medicare rules say that cosmetic surgery to reshape the breasts to improve 
appearance is not a Medicare benefit. 
 
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 breast reduction. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that you have macromastia. The record indicates that you have a body surface area 1.81 cubic meters with 
between 200-300 grams of tissue. The amount to be removed is beneath the required amount enumerated in the 
coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not 
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 a breast reduction have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a breast reduction.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the service was rendered due to 
medical necessity. You also say that patient care was provided as an urgent request from the referring provider 
to avoid wound complications such as: deterioration, amputation, infection and or hospitalization. The Plan 
denied your request. The Plan says the services are not authorized because this provider is a non-network 
provider. The Plan also says that the member was referred by a provider who also does not work with the 
member's plan, and the member's primary care physician did not refer for services. 
 
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 provided on April 
28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the coinsurance for a bladder procedure provided from 
February 22, 2022, to March 8, 2022. 
 
You asked the Plan to lower the coinsurance for a bladder procedure. You say that you want this lowered to 
$300, which you were prepared for, but not the $954. The Plan denied your request. The Plan says the cost 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 40% 
coinsurance for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Center. $318.13 X 3 dates of service = $954.39. 
 
You have been asked to pay a $954.39 coinsurance for a bladder procedure. A bladder procedure falls within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Center 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 lower the coinsurance for a bladder procedure provided from February 
22, 2022, to March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that due to your medical issues you would like 
approval to see the provider. The Plan denied your request. The Plan says the service can be provided by an in-
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 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 
office visit 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 pre-approve repeat epidural steroid injection services. 
 
You asked the Plan to pre-approve repeat epidural steroid injection services. You say that this procedure is 
medically necessary for the enrollee's condition. 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 repeat epidural steroid injections when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months. 
 
We looked at the file and Medicare rules. In this case, the documentation indicates that the previous epidural 
steroid injection only provided 40% pain relief, not the required 50% pain relief. Based on this information, we 
decided that Medicare rules for coverage of repeat epidural steroid injection services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve repeat epidural steroid injection services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on April 18, 2022. 
 
You asked the Plan to waive the copayment for an ECG. You say that you should not have a copayment 
because your provider required you to have the services completed. 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 an $85 
copayment for basic radiological services performed at an outpatient hospital.  
 
You have been asked to pay $55.75, which is less than the standard $85 copayment for an ECG. An ECG 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 ECG provided on April 18, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox injections (J0585 and 52287). 
 
You asked the Plan to pre-approve Botox injections (J0585 and 52287). You say that the requested Botox 
injections are medically necessary. The Plan denied your request. The Plan says that the enrollee must try 
Anticholinergic medications first and the request is not medically necessary. 
 
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. The Plan's denial rationale is not clear enough to make a determination based on 
Medicare criteria. The Plan is using step therapy criteria stating the enrollee must try and fail Anticholinergic 
medications first before Botox will be approved; however, per the Plan's Evidence of Coverage (EOC), the 
Plan's preferred step therapy drugs for Botox are either Dysport or Xeomin. The Plan also states in their 
rationale that the denial is based on medical necessity and that the denial of Botox was appropriate given the 
enrollee's clinical scenario. We are unable to determine what Medicare criteria to follow based on the Plan's 
failure to send a clear denial rationale. We find that the Plan has not substantiated their reasoning for denial 
based on Medicare criteria. Therefore, we decided that the Plan has to pre-approve Botox injections (J0585 and 
52287).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty. 
 
You asked the Plan to pre-approve arthroplasty. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve arthroplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for primary osteoarthritis of the left shoulder. The enrollee 
presented with left shoulder pain. The enrollee notes a limited range of motion. The pain is in or near the 
shoulder joint and is made worse with lifting and grasping. The problem is getting worse and has been present 
for six to eight months. The exam reveals tenderness to palpation of the global shoulder region. The range of 
motion is limited at painful at extremes. There is positive cogwheel and crepitus. The strength is four out of 
five in subscapularis and three out of five in the supraspinatus. Neers testing is positive. However, detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. Additionally, advanced diagnostic imaging was not provided or documented that demonstrated rotator cuff pathology to support the requested procedure. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroplasty.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on March 
14, 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 March 14, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921) provided on 
April 18, 2022. 
 
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 this service is not a covered benefit under 
your contractual policy. 
 
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, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigationper quadrant (D4921) provided on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on May 18, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the copayment should be paid for by the 
Plan because you are not supposed to have a copayment from an x-ray performed in-house. 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 $90 
copayment for diagnostic procedures and tests performed at an outpatient hospital.  
 
You have been asked to pay $78.06, which is less than the standard $90 copayment for an x-ray. An x-ray 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 x-ray provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a women's health test provided on May 10, 
2022. 
 
You asked the Plan to waive the deductible for a women's health test. You say that this should be a routine test 
and not have a copay. You do not understand why you are receiving this bill. The Plan denied your request. 
The Plan says the deductible 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 $250 
deductible for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $35.09 as part of your deductible for a women's health test. A women's health test 
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 deductible for a women's health test provided on May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee is diagnosed with idiopathic orofacial 
dystonia and the requested Botox is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested Botox. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet criteria for the requested Botox. Our physician reviewer found the record indicates that 
the enrollee has temporomandibular joint dysfunction. Upon appeal the prescriber indicates that the enrollee 
has orofacial dystonia. The provided records support the former diagnosis and does not credibly support the 
appeal diagnosis. The record provided does not establish that the enrollee has a condition enumerated in the 
coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not 
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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on November 09, 2021. 
 
You asked the Plan to waive the copayment for x-rays. You say that you feel it should only be a $20 
copayment. 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 $150 
copayment per visit for all other services furnished at a hospital outpatient facility (except for Cardiovascular / 
Pulmonary Rehabilitation and Supervised Exercise Therapy  see those sections in this Benefit Chart). We 
cover medically necessary services you get in the outpatient department of a hospital for diagnosis or treatment 
of an illness or injury. Covered services include but are not limited to X-rays and other radiology services 
billed by the hospital. 
 
 
 You have been asked to pay a $150 copayment for x-rays. X-rays fall within the Outpatient hospital services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for x-rays on November 09, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from 
December 23, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were never told these 
copayments would be so high. You need them waived. 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 $150 
copayment for outpatient hospital services.  
 
You have been asked to pay a $99 copayment, rather than the full copayment amount of $150 for physical 
therapy visits. Physical therapy visits fall within the Outpatient Hospital Services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for physical therapy visits provided from December 23, 2021, to 
December 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for x-rays and office visit on August 26, 2021. 
 
You asked the Plan to waive the copayments for x-rays and office visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged 
is correct. 
 
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. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the copayment being charged is correct.  Therefore, we decided that the Plan has to waive the 
copayments for x-rays and office visit on August 26, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on May 4, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you just retired and are unable to 
afford the copayment. 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $325 copayment per day 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 CT scan provided on May 4, 2022.