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

 
We decided that the Plan has to pre-approve a percutaneous image-guided lumbar decompression (PILD) 
procedure. 
 
You asked the Plan to pre-approve the PILD procedure. You say that the enrollee meets all criteria for this 
procedure to be rendered. The Plan denied your request. The Plan says that this can only be covered for those 
in an approved study. There is no evidence of this, meaning the denial is correct. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan's sole denial rationale is that the enrollee is not participating 
in a clinical trial as required by the NCD. However, the appeal letter clearly references a trial NCT03072927. 
This is a Medicare claims study that tracks data for all Medicare patients who receive the requested PILD 
surgery and all patients who receive a standard lumbar decompression and compares these to meet the CED 
requirements. This study enrolls the patient at the time the procedure is rendered, and there is no prospective 
enrollment prior to the procedure being performed. As such, the denial based on lack of an approved clinical 
study is not supported. Therefore, we decided that the Plan has to pre-approve a percutaneous image-guided 
lumbar decompression (PILD) procedure.  
 
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 office visit provided on August 03, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 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 office visit provided on August 03, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot x-ray provided on March 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a foot x-ray. You say that this should be covered. The Plan denied your request. 
The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an 
out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a foot x-ray provided 
on March 14, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
9, 2022 to May 18, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the denial. 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 $325 
copayment per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $325 copayment for 1 day of inpatient hospital care and then a $1,950 
copayment for 6 days of inpatient care after being transferred to a different facility. 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. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided from May 9, 2022 to May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit by the Plan or by 
Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you should not be responsible 
for this cost. 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 $370 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $299.25, which is less than the standard $370 copayment for outpatient surgery. 
This outpatient surgery falls within the Outpatient surgery and other medical 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 waive the 
copayment for wound care provided on May 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on June 10, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you disagree with the 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service falls within the 
emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit 
provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED) 
provided on May 8, 2022, and June 8, 2022. 
 
You asked the Plan to waive the coinsurance for the AED. You say that you did not know there was a charge 
for each month. 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 20% 
coinsurance for in-network Medicare-covered benefits. On May 8, 2022, the total allowed amount was 
$2,704.94 with a coinsurance of $540.99. On June 8, 2022, the total allowed amount was $2,704.94 with a 
coinsurance of $540.99. The total coinsurance amount for both dates of service was $1,081.98 ($540.99 
coinsurance + $540.99 coinsurance). 
 
  You have been asked to pay a $1,081.98 coinsurance for the AED. This item/service falls within the Durable 
Medical Equipment (DME) and Related 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 
coinsurance for the automatic external defibrillator (AED) provided on May 8, 2022, and June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram (EKG) provided on June 01, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for EKG. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says our plan covers all medical services that are medically necessary, these services are 
listed in the plans Medical Benefits C hart (this chart is in Chapter 4 of this booklet) and are obtained 
consistent with plan rules. The enrollee is responsible for paying the full cost of services that arent covered by 
our plan, either because they are not plan covered services, or they were obtained out -of-network and were not 
authorized. 
 
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 electrocardiogram (EKG) provided on June 01, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastric bypass and Roux-En-Y gastroenterostomy. 
 
You asked the Plan to pre-approve gastric bypass and Roux-En-Y gastroenterostomy. 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 effective for services performed on and after 
February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic 
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch 
(BPD/GRDS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries 
who have a body-mass index = 35, have at least one co-morbidity related to obesity, and have been previously 
unsuccessful with medical treatment for obesity. 
 
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 gastric bypass and Roux-En-Y 
gastroenterostomy. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, the record indicates that the enrollee has morbid obesity and underwent a gastric sleeve 
procedure in 2019. She subsequently has had insufficient weight loss. The record indicates that the enrollee has 
uncomplicated gastroesophageal reflux and small hiatal hernia. The provided record does not include primary 
source documentation of attempted conservative treatment of the gastroesophageal reflux or any testing results 
to review. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastric bypass and Roux-En-Y gastroenterostomy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve gastric bypass and Roux-En-Y gastroenterostomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing. 
 
You asked the Plan to pre-approve BRCA testing. 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 NGS is covered when specific criteria are met. 
 
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 BRCA testing. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found screening genetic testing is not a 
covered benefit. Testing of individuals with no personal history of breast, ovarian, fallopian tube, primary 
peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare 
statute. 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 BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on July 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that you are appealing with supporting records The 
Plan denied your request. The Plan says the enrollee must receive care from a 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 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 pathology services provided on July 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on July 07, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. 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 $290 
copayment for each Medicare-covered ambulatory surgical center visit. If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-
sharing amounts for outpatient surgery. 
 
You have been asked to pay a $290 copayment for colonoscopy. This item/service falls within the Outpatient 
surgery 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 colonoscopy on July 07, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a qualifying diagnosis for this wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the  
clinical documentation is insufficient why a lower-level power wheelchair would not suffice for her needs 
versus a group 3 power wheelchair. She does not have a neurological condition, myopathy or significant 
skeletal deformity that would require a group 3 power wheelchair. There is also inadequate clinical 
documentation regarding why she requires power tilt and recline and cannot perform pressure relief. There is 
also no significant lower extremity edema or spasticity that would require power elevating leg rests. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a vedolizumab injection provided on 
March 16, 2022. 
 
You asked the Plan to waive the coinsurance for a vedolizumab injection. You say that you had changed your 
plan, and the new amounts are so much higher, you cannot afford them. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $1,341.46 coinsurance for a vedolizumab injection. 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a vedolizumab injection provided on March 16, 2022.  
 Your complaint about the Plan representative signing you up for a more expensive plan 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.