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

 
We decided that the Plan does not have to pre-approve an out-of-network referral for oncology services. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the available medical information does not support the need for an authorization to a 
non-plan 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 
an out-of-network referral for oncology services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve psychotherapy services. You say that you have been unable to see an in-
network provider for medication maintenance. The Plan denied your request. The Plan says rules for out-of-
network care have not been met. 
 
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 
psychotherapy services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee on July 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no authorization for these 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 outpatient services provided to the enrollee on 
July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a modular entry ramp for a wheelchair. 
 
You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a modular entry ramp for a wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 22, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $0 
copayment for advanced imaging services provided at a primary care providers office, specialists office or 
stand-alone imaging center and a $195 copayment when provided at an outpatient hospital facility. 
 
You received an ultrasound on June 22, 2021, at an outpatient hospital facility. Therefore, you are responsible 
to pay the allowed amount of $113.70, which is less than the $195 copayment.   
 You have been asked to pay $113.70 for an ultrasound. An 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 an ultrasound provided on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 6, 2021, 
through July 7, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given fluid intravenously 
along with something else. You say that you want to know why this wouldn't be covered. The Plan denied your 
request. The Plan says self-administered drugs are not covered under 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 pay for the self-administered drugs 
provided from July 6, 2021, through July 7, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve MAZE heart surgery (CPT code 33258), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. You state the 
enrollee has persistent atrial fibrillation and has failed conservative medical management with anti-arrhythmic 
drug adjustments. The Plan denied your request. The Plan says that convergent MAZE surgery is considered 
not medically necessary in the treatment of persistent atrial fibrillation as the clinical trial studying the safety 
and effectiveness of the surgery is not complete. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has failed two catheter only ablation attempts and has recurrent prolonged atrial 
fibrillation (AF) episodes with symptoms and is intolerant of the most likely effective drug for maintenance of 
normal sinus rhythm (NSR), namely amidoarone. As such in this clinical situation, and based on the 
randomized published data to date, a convergent MAZE procedure would offer the enrollee the best option for 
the treatment of her AF recurrence, is medically reasonable and necessary and not investigational in this very 
specific set of clinical circumstances when using the "heart team approach". A convergent ablation procedure 
would therefore meet the applicable Centers for Medicare & Medicaid Services (CMS) criteria of Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve MAZE heart surgery (CPT code 33258), for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refractions (92015) provided April 20, 2021. 
 You asked the Plan to pay for the refractions. You say that the refractions are a covered benefit. The Plan 
denied your request. The Plan says only routine eye exams are covered. Refractions as part of a medical eye 
exam are non-covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by contract providers as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The service was part of a medical eye exam and not a routine vision 
screening. Based on this information, we decided that the Plan's rules for coverage of the refractions have not 
been met. Therefore, we decided that the Plan does not have to pay for refractions (92015) provided April 20, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the setup work and supplies associated with providing 
mobile anesthesia services for an endoscopy procedure on March 30, 2021 described by codes A4550, A4556, 
A4557, A4649, E0600-RR, A9999, S1015-NU, S8301, and 99072. 

 You asked the Plan to pay for the mobile anesthesia setup work and supplies as billed. You say that you believe 
that this should be paid as you are providing all equipment needed to provide this anesthesia is an office 
setting. As none of this is provided by the surgeon, you feel that you should be reimbursed for these items. The 
Plan denied your request. The Plan says codes 99072, S1015, and S8301 are not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for anesthesia services is made through 
the five-digit anesthesia code billed, as base value plus time units. No separate payment is made for drugs, 
supplies, or materials. 

Therefore, we decided that the Plan does not have to pay for the setup work and supplies 
associated with providing mobile anesthesia services for an endoscopy procedure on March 30, 2021 described 
by codes A4550, A4556, A4557, A4649, E0600-RR, A9999, S1015-NU, S8301, and 99072.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electrical bone growth stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the medical records do not show that the criteria has been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 stimulator. Our reviewer says that 
the requested stimulator is medically reasonable and necessary. Our physician reviewer found there is no 
documentation of serial x-rays over a 3-month period evidencing no progressive healing to support the 
diagnosis of non-union at this time. However, the x-rays dated 8/11/21 do reveal diffuse osteopenia, which 
would be a significant risk factor for failed or non-union of fracture. The individual has been persistently 
wheelchair confined, in addition. Therefore, the request for the electrical bone growth stimulator would be 
considered medically necessary and appropriate, as an indicated relative exception. 
 
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 stimulator have been met. Therefore, we decided that the Plan has to pre-
approve an electrical bone growth stimulator.  
 
 
 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 a laparoscopic partial gastrectomy with Roux-en-Y 
(43659). 
 
You asked the Plan to pre-approve a laparoscopic partial gastrectomy with Roux-en-Y. You say that the 
requested procedure is a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for the requested procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules specify the ICD-10-CM codes that support medical 
necessity for CPT codes including 43659. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a laparoscopic partial gastrectomy with Roux-en-Y have not been met. Specifically, the diagnosis 
codes in the available medical record are not among those specified by the Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve a laparoscopic partial gastrectomy with Roux-en-Y (43659).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you were in a car wreck in May. You say that 
you lost your upper plate in the wreck. You also say that you need a new upper plate. The Plan denied your 
request. The Plan says 1 upper denture is covered every 60 months. The Plan also says that the frequency limit 
has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and complete upper denture is a 
covered item, the frequency limit has been reached. The record shows that the Plan paid for an upper denture 
that you received on March 25, 2021. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy coded as 97014 provided on 
October 27, 2020. 
 
You asked the Plan to pay for the electric stimulation therapy. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was 
billed with a CPT code which is invalid for usage with Medicare. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97014 is application of a modality to 1 or more areas; 
electrical stimulation (unattended). 
 
We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status 
indicator of ?I? which indicates this code is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for the electric stimulation therapy coded as 97014 provided on 
October 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MASE procedure. 
 
You asked the Plan to pre-approve a MASE procedure. You say that the requested procedure is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because 
the requested procedure is experimental/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 a MASE procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested procedure is not standard of care and as such cannot be considered medically 
necessary in lieu of more conventional management approaches for your condition. 
 
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 MASE procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MASE procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided July 30, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you 
were unaware the services would be rendered and therefore could not check your benefits. The Plan denied 
your request. The Plan says you have exceeded the frequency limits for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the 
comprehensive oral exam and complete series of x-rays when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and complete series of x-rays were previously covered on October 15, 2019. Based on this information, 
we decided that the Plan's frequency limit for coverage of the comprehensive oral exam and complete series of 
x-rays have been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images 
(D0210) provided July 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation 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 before radiofrequency ablation services can be 
covered, patients must have had at least two medically reasonable and necessary diagnostic MBBs.  
 
We looked at the file and Medicare rules. In this case, there is only evidence that one diagnostic MBB was 
performed at this time. Based on this information, we decided that Medicare rules for coverage of 
radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical supplies used during an outpatient 
cardiac procedure you had on May 19, 2021. 
 
You asked the Plan to waive the coinsurance for the surgical supplies. You say that you believe the hospital 
coded this procedure incorrectly and that your cost sharing should be limited to $300. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 surgical supplies.  
 
Records show that during the outpatient cardiac ablation procedure you had, multiple types of medical supplies 
were used during the procedure. The hospital billed each type of supply as a separate line item on the bill. You 
have been asked to pay 20% coinsurance for the surgical supplies. According to your contract, you pay separate 
cost sharing (beyond the cost of the surgery itself) for surgical supplies. 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 coinsurance for surgical supplies used during an outpatient cardiac procedure you had on May 19, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 is gradually improving. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that she is not currently receiving but that would be available at the LTACH facility. 
 
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.