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

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on August 24, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you are on limited income and have 
many bills due to your cancer. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 per 
day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 
  You have been asked to pay $250 for the CT scan. The 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 the computed tomography (CT) scan provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee is no longer receiving IV antibiotics. His sacral/buttock care is not complex. 
The frequency of the enrollees heel care is unclear.  He does not have documented skilled therapy needs. The 
enrollee is non-ambulatory at baseline. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided at a lower level of care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve Vraylar. You say that the enrollee has been stable on this medication since 
2021. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan 
says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says 
the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 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 pre-approve Vraylar.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removal of malignant lesion (17261) provided on February 
21, 2022. 
 
You asked the Plan to pay for a removal of malignant lesion. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that destruction of malignant skin lesions will be 
considered medically necessary when the criteria listed in the Medicare rules section have been met. 
 
 
  We looked at the file and Medicare rules. In this case, the available medical records do not document the 
removal of a malignant lesion. Based on this information, we decided that Medicare rules for coverage of a 
removal of malignant lesion have not been met. Therefore, we decided that the Plan does not have to pay for a 
removal of malignant lesion (17261) provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
wound care services. We found no exception that would require the Plan to pay for the wound care services. 
The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for wound care services provided on January 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on January 4, 2022, by an out-of-network 
provider. 
 
You asked the Plan to pay for the x-ray. You say that the provider requesting this service is part of your 
network and should have requested authorization for these services. The Plan denied your request. The Plan 
says the provider is not a network provider and 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 the x-ray provided on January 4, 2022, by an out-
of-network provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician attendance.  
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician attendance. 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 hyperbaric oxygen (HBO) therapy will be limited to 
specific circumstances. 
 
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 hyperbaric oxygen therapy with 
physician attendance. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the review indicates that the female enrollee has a chronic ulceration of the left thigh and known 
peripheral vascular disease in the leg. She has had an above the knee amputation in this leg previously. The left 
thigh wound began as an abscess in February 2022 but is not healing well. The enrollee has a has a cutaneous 
wound with chronic peripheral vascular insufficiency, a condition for which that hyperbaric oxygen treatment 
is not covered by Medicare. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy with physician attendance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician 
attendance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 18, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this testing reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on January 
18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram and the ultrasound provided on September 
7, 2021, by an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the mammogram and the ultrasound. You say that the services were medically 
necessary and consistent with local and national standards of medical practice based on the enrollee's condition. 
The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
mammogram and the ultrasound. We found no exception that would require the Plan to pay for the 
mammogram and the ultrasound. The records provided for review do not show that the services at issue were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the mammogram and the 
ultrasound provided on September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee's previous lumbar medial branch 
block injections have improved the enrollee's quality of life. The Plan denied your request. The Plan says that 
records show that the enrollee has already had four diagnostic joint sessions in the lumbar region within the 
past twelve months. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than four (4) diagnostic joint sessions 
will be reimbursed per rolling 12 months.  
 
We looked at 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 
facet joint injections (64493, 64494) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your nebulizer stopped 
working and this is the reason you needed to the ambulance ride. You would not have needed Emergency 
Services if this had not occurred. 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these services. 
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 ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by requested out-of-network 
dialysis center. 
 
You asked the Plan to pre-approve dialysis to be provided by the requested out-of-network dialysis center. The 
Plan denied your request. The Plan says this facility is not contracted with the Plan effective June 1, 2022. The 
Plan has a contracted facility that is available to offer the same service at the same distance. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve dialysis to be provided by the requested out-
of-network dialysis center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to go to the LTACH. 
The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available in the 
current acute care hospital. All medically necessary services are being provided in the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. The Plan denied your request. The 
Plan says radiofrequency ablation to the SI joint is experimental or investigational. 
 
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 radiofrequency ablation to the SI joint. 
Our reviewer says that radiofrequency ablation to the SI joint is not considered medically reasonable and 
necessary. Our physician reviewer found that according to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint, (code 64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are weak, and you feel that IRF care is medically 
necessary. The Plan denied your request. The Plan says you are enrolled in a federal Medicare-certified 
Hospice Program. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
You are under the Medicare hospice benefit as of April 27, 2022. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for wounds care services provided on January 
20, 2022. 
 
You asked the Plan to reduce the copayment for the wound care. You say that you were never charged more 
than a $32 copayment previously. 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 $310 
copayment for each outpatient hospital visit.  
 
You have been asked to pay a $310 copayment for the wound care. The wound care 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. Therefore, we 
decided that the Plan does not have to reduce the copayment for wounds care services provided on January 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits and an injection on February 
23, 2022, to March 11, 2022. 
 
You asked the Plan to waive the copayment for office visits and an injection. You say that you would like to 
appeal the cost share. 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 $25 
copayment and a 20% coinsurance for office visits and an injection. The total allowed amount of the injection 
is $602.19, resulting in a coinsurance amount of $120.44. The coinsurance amount, $120.44, in addition to the 
two office visits makes the total cost share $170.44. 
 
You have been asked to pay a $25 copayment for each specialist doctor visit for Medicare-covered services and 
a 20% coinsurance for office visits and an injection. An injection and an office visit fall within the Medicare 
Part B prescription drugs and Physician/practitioner services, including doctors office visits benefit categories. 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 injection and an office visit on February 23, 2022, to 
March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip revision (27134). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no indication of prosthetic failure on the recently obtained 
imaging. 
 
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. Detailed 
documentation is not evident regarding any loosening, fracture, or prosthetic defects on the imaging studies. 
The documentation does not indicate that there have been any dislocations or any clinically significant leg 
length inequality. The lab work did not demonstrate any signs of infection. Progressive or substantial bone loss 
and bearing surface wear are not evident. The documentation does not indicate an audible noise and does not 
corroborate adverse local tissue reactions. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this overall clinical, imaging and laboratory setting. Our 
physician reviewer found that your 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 a hip revision (27134).