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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on June 15, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that you 
should not have to pay this copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for a magnetic resonance imaging (MRI) scan. This 
item/service 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 magnetic resonance imaging (MRI) scan provided on June 
15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided on March 
11, 2022, to March 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you were told this would 
be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $1,890 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,890 copayment for inpatient rehabilitation. This item/service falls within the 
inpatient hospital 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.You also say you are appealing this cost sharing as it was misrepresented to you. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided 
on March 11, 2022, to March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
August 18, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you should not have a 
copayment for this, the provider told you this had to be done. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for a diagnostic mammogram. This item/service 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.$20 x 2 diagnostic pictures = $40 total. Therefore, 
we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injections provided on 
March 09, 2022, to May 11, 2022. 
 
You asked the Plan to waive the coinsurance for the aflibercept injections. You say that these services should 
be covered in full. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the aflibercept injections. This item/service falls within the 
Medicare Part B prescription drugs 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.The allowed amount for each injection is $1,831.50, and the 20% coinsurance 
applied is $366.30. The total for both injections is $732.60. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the aflibercept injections provided on March 09, 2022, to May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental evaluation (D0150) and panoramic 
x-ray (D0330) provided on July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a bad experience with the previous 
dentist. You also say that you were still experiencing pain. The Plan denied your request. The Plan says your 
benefits for the comprehensive oral evaluation and panoramic x-ray have already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefits for the comprehensive oral evaluation and panoramic x-ray were exhausted on date of 
service May 5, 2022. Therefore, we decided that the Plan does not have to pay for the comprehensive dental 
evaluation (D0150) and panoramic x-ray (D0330) provided on July 27, 2022.  
 Your complaint about the pain caused by your previous extraction is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement, muscle or fascia, (11043) provided on July 
18, 2022. 
 
You asked the Plan to pay for the wound care. You say that the treatment provided to the enrollee was 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before 
the service 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the debridement, muscle or fascia, (11043) provided on July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of spinal neurostimulator to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided will show 
proof of medical necessity for the requested service. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 
the insertion of spinal neurostimulator 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 Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are requesting a formal 
determination so you may pursue coverage through other sources. The Plan denied your request. The Plan says 
the enrollee does not have a qualifying diagnosis for a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents (72146). 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. The Plan denied your request. The 
Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the spinal canal and 
contents. Our reviewer says that an MRI of the spinal canal and contents is not reasonable and necessary for the 
enrollee. Our physician reviewer found there is an MRI of the thoracic spine dated August 18, 2022, which is 
compared to March 2, 2022, showing no interval change in the appearance of the thoracic cord. Notation is 
made of intramedullary plaques compatible with multiple sclerosis, but no enhancement or cord swelling to 
indicate active disease. Our reviewer found the medical necessity for the requested MRI of the thoracic spine is 
not explained by any chart notes indicating the enrollee's therapy or clinical findings. Our physician reviewer 
also found that without any clinical information in addition to the diagnosis of multiple sclerosis, which is 
listed as the indication for the August 18, 2022 MRI, the medical necessity of the requested MRI of the thoracic 
spine is not established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents (72146).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you want to continue the care since you have been 
treated by them for three years. The Plan denied your request. The Plan says the services can be obtained 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 visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial 
area. 
 
You asked the Plan to pre-approve a CT scan of the maxillofacial area. The Plan denied your request. The Plan 
says the medical records provided do not show that the enrollee meets the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the maxillofacial area. Our 
reviewer says that a CT scan of the maxillofacial area is not reasonable and necessary. Our physician reviewer 
found the enrollee was seen on October 28, 2022, with right facial swelling for which they were prescribed 
Augmentin for 7 days, and to return to the clinic in 3 months if no improvement. Facial exam on October 28, 
2022, revealed painful swelling. Our reviewer found no temperature or complete blood count was recorded on 
that date. The 7-day course of Augmentin therapy was supposed to begin on the encounter date of October 28, 
however, that therapy and clinic visit were over 6 weeks ago and no notes or evidence of evaluation after 
completion of the antibiotic therapy is in the records submitted. Our physician reviewer also found that without 
such records, the medical necessity of a CT of the sinuses and facial bones cannot be established in the records 
submitted. 
 
 
 
 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 CT scan of the maxillofacial area have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial area.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is 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 cardiac catheterization. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has had atypical chest pains thought most consistent with gastroesophageal 
reflux disease. Stress testing showed no evidence of cardiac ischemia. The available documentation does not 
support the rationale for the requested invasive imaging study. Guidelines do not support a need for cardiac 
catheterization in this clinical 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve RFA. You say that you have received several steroid shots in your knee 
previously. You say that they have not been as effective as in the past. You say that you were advised that RFA 
would help you be more active and lose weight. You also say that many other Medicare providers cover RFA. 
The Plan denied your request. The Plan says the requested service is 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 RFA. Our reviewer says that the 
requested genicular RFA is not considered medically reasonable and necessary in this case. Our physician 
reviewer found here is insufficient evidence in the literature on the effectiveness of this procedure and thus 
considered experimental. Therefore, the reviewer found that a genicular RFA is 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve genicular radiofrequency ablation (RFA) (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770) and 
miscellaneous durable medical equipment (E1399). 
 
You asked the Plan to pre-approve the Bioness L300 Go lower cuff system. You say that you tried the Bioness 
device during a physical therapy session on July 7, 2022, and it improved your ability to walk. The Plan denied 
your request. The Plan says the Bioness stimulator is considered experimental, investigational and/or unproven. 
 
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. This treatment has not been shown to work for foot drop from a 
stroke. Based on this information, we decided that Medicare rules for coverage of the Bioness L300 Go lower 
cuff system have not been met. Therefore, we decided that the Plan does not have to pre-approve the functional 
electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not 
otherwise specified (E0770) and miscellaneous durable medical equipment (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck. 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that your doctor wants to do this CT scan 
prior to doing an ultrasound biopsy because it would better help before further testing is needed. The Plan 
denied your request. The Plan says there is not sufficient information provided to determine that the neck CT 
scan is reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the neck. Our reviewer 
says that a CT scan of the neck is not reasonable and necessary. Our physician reviewer found you had a right 
submandibular mass seen on an ultrasound on August 23, 2022. Our reviewer found that subsequently, a CT 
guided biopsy of this mass was done on November 1, 2022, which revealed salivary gland and adjacent muscle. 
Our physician reviewer also found that the justification for doing another CT of the neck is not explained in the 
submitted records. 
 
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 CT scan of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the neck.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service June 21, 2022. 
 
You asked the Plan to pay for code A0425. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim.  
 
In this case, the MUE for code A0425 is 250. The MAI value for this code is 1. The services were billed on one 
claim line. You billed 415 units of this code, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of code A0425 have not been met. Therefore, we decided that the Plan does not 
have to pay for code A0425 billed for date of service June 21, 2022.