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

 
We decided that the Plan does not have to waive the copayment for a duplex scan (ultrasound) of extracranial 
arteries provided on October 26, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the treatment received was 
ineffective. 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 $225 
copayment for advanced imaging services, including ultrasounds.  
 
You have been asked to pay $100, which is less than the $225 copayment for the ultrasound. The ultrasound 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a duplex scan (ultrasound) of extracranial arteries provided 
on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided by a 
participating provider on October 22, 2021. 
 
You asked the Plan to waive the copayment for physician services. You say that there should not be a 
copayment for an annual wellness visit. The Plan denied your request. The Plan says the correct copayment has 
been applied. 
 
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 physician/practitioner services/specialist.  
 
You have been asked to pay a $20 copayment for physician services. The correct copayment has been applied 
to the services that were provided. Physician services fall within the physician/practitioner services/specialist 
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 physician services provided by a 
participating provider on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service is payable by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower part of 
the spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no conservative treatment. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no neurological 
exam in the submitted records. Hence, no red flag is documented to support the need for MRI, without a six 
week trial of physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower part of the spine for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiation therapy services provided by a plan-participating 
dermatologist from October 14, 2021, to November 16, 2021. 
 
You asked the Plan to pay for the radiation therapy services. You say that you were approved for 16 radiation 
therapy treatments, but when you called the Plan, they told you that you only had approval for one treatment. 
The Plan denied your request. The Plan says that procedure code 77280 was not authorized, so these claims 
denied correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided these radiation therapy services by a contract provider. The file does not show that the Plan 
provided notice that the radiation therapy services would not be covered. This contract provider is supposed to 
know when authorization is required, and they should know to not provide services without authorization that 
require authorization.  This contract provider failed to do that.  Apparently, even though only one session of 
radiation therapy had been approved, this provider proceeded to provide 15 more sessions without advising 
you, in writing, that they would not be covered. Under Medicare rules, this means the radiation therapy services 
is considered approved by the Plan. Therefore, we decided that the Plan has to pay for radiation therapy 
services provided by a plan-participating dermatologist from October 14, 2021, to November 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not does not 
require frequent adjustment of insulin dosage based on blood glucose results.. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy services (97161) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient therapy services. You say that the services are medically 
necessary and you are currently in Kentucky. The Plan denied your request. The Plan says the records do not 
show that these services are emergent, and no physician order was provided for therapy 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 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. Additionally, no physician order for physical therapy was provided in the 
included records. Therefore, we decided that the Plan does not have to pre-approve outpatient therapy services 
(97161) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy, flexible; diagnostic, including collection 
of specimen(s) by brushing or washing, when performed (45378). 
 
You asked the Plan to pre-approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by 
brushing or washing, when performed (45378). You say that a colonoscopy is medically necessary. The Plan 
denied your request. The Plan says a colonoscopy is not medically necessary. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a colonoscopy, flexible; diagnostic, 
including collection of specimen(s) by brushing or washing, when performed (45378). Our reviewer says that a 
colonoscopy is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
a history of colonic polyps in the distant past. The record indicates that the enrollee had a colonoscopy in  
May 2015 that did not reveal polyps. The provided records are insufficient to establish that an enumerated 
indication, as defined by the local coverage determination, exists for coverage to be available for the requested 
service. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 colonoscopy, flexible; diagnostic, including collection of specimen(s) by 
brushing or washing, when performed (45378) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or 
washing, when performed (45378).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), an intraoral, 
periapical first radiographic image (D0220) and endodontic therapy (D3330) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a limited oral evaluation, an intraoral image and endodontic therapy. You 
say that the provider the Plan wanted you to go to was out of reach from your driving ability. You also say your 
husband who normally drove you, had a stroke and is unable to drive. It is very difficult for you to get 
downtown or to go east of where you live. The Plan denied your request. The Plan says the requested services 
can be met in-network. The Plan also says there are 6 in-network providers within a 20-mile radius of your zip 
code. 
 
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.  
 
 
 We looked at the file and Medicare rules. The EOC confirms that you must see a participating provider to 
receive dental services. Based on this information, we decided that the Plan's rules for coverage of a limited 
oral evaluation, an intraoral image and endodontic therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a limited oral evaluation (D0140), an intraoral, periapical first radiographic 
image (D0220) and endodontic therapy (D3330) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for coverage. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found as a practical matter this enrollee 
does not require the necessary services on 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
10, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this was part of an annual 
visit and should be covered. 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 $35 
copayment for laboratory services provided at an outpatient hospital facility.  
 
The file shows that the visit was not billed as an annual visit, only lab work was included. Therefore, you have 
been asked to pay $19.23, which is less than the $35 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on December 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of Skilled Nursing Facility (SNF) 
services beyond March 24, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does 
not meet Medicare criteria for coverage. 
 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 the continuation of SNF services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's 
functional level does not require skilled therapy services with the specialized skill, knowledge, and judgment of 
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on 
a "daily basis" in a SNF. 
 
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 continuation of SNF services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the continuation of Skilled Nursing Facility (SNF) services beyond 
March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc injections. 
 
You asked the Plan to pre-approve the GenVisc injections. You say that this treatment is required. The Plan 
denied your request. The Plan says the step therapy rules require a trial of Orthovisc or Synvisc prior to 
approving GenVisc. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 GenVisc injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the record indicates that the enrollee has osteoarthritis of the knees.  The requested 
medication is a new start.  The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would 
have an adverse effect from the plan's preferred step one alternative.  The elements of the coverage criteria are 
not satisfied.  
 
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 GenVisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve GenVisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rectal prostate spacer (55874). 
 
You asked the Plan to pre-approve the rectal prostate spacer. You say that the spacer is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that prostate rectal spacers are covered when 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 the rectal prostate spacer. Our reviewer 
says that the requested spacer is not medically necessary. Our physician reviewer found the submitted 
information does not show that the member will receive conventional fractionation or moderate 
hypofractionation. The enrollee does have one of the exclusion criteria since he has had prior prostate cancer 
treatment with CyberKnife stereotactic body radiation therapy.  
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 rectal prostate spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a rectal prostate spacer (55874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (Thermal destruction of 
intraosseous basivertebral nerve). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that Intracept fills a treatment gap for those 
who do not receive adequate relief from other treatments but do not require spinal fusion. The Plan denied your 
request. The Plan says this treatment is not currently supported in the available literature. 
 
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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to support medical 
necessity. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (Thermal destruction of intraosseous basivertebral nerve).