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

 
We decided that the Plan does not have to pay for the echocardiography provided on July 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the echocardiography. You say that you had services rendered prior from this 
provider and you needed a checkup. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and the enrollee's primary care provider did not refer the enrollee to the OON provider. Also, a 
review of the claims history did not reveal the enrollee has seen this specialist since enrolled in the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the echocardiography provided on July 30, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital outpatient clinic visit provided on February 2, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Hospital outpatient clinic visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Hospital outpatient clinic visit provided on 
February 2, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia tab 10mg. 
 
You asked the Plan to pre-approve Kerendia. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says this medication falls under Part D 
coverage. Drugs covered under Part Dare not eligible for coverage under Part B benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Kerendia tab 10mg.  
 
 
 
 
 
 Benefits for Kerendia 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetro 4MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary for nausea caused 
by a small bowel obstruction. The Plan denied your request. The Plan says this medication is not covered under 
the enrollee's Part B benefit due to the diagnosis. 
 
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. Review of the file shows that a small bowel obstruction is causing nausea. Therefore, this 
medication is not covered because it will not be used for nausea caused by chemotherapy. Therefore, we 
decided that the Plan does not have to pre-approve Ondansetro 4MG tablet.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy 100mg tablets. 
 
You asked the Plan to pre-approve Ubrelvy. You say that Ubrelvy is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy 100mg tablets.  
 
Benefits for Ubrelvy 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: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs) for the enrollee. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee had 2 prior L1-L2 MBBs at L1 - L2 on 8/19/2021 with 50% pain relief, and 
on 2/24/2022 with 80% pain relief. 
 
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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve repeat medial branch blocks (MBBs) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve High-intensity Focused Ultrasound (HIFU) treatment. 
 
You asked the Plan to pre-approve HIFU treatment. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been 
met. 
 
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 HIFU treatment. Our reviewer says that 
you do not meet LCD criteria for coverage. Our physician reviewer found the records do not show that you 
have had primary radiation treatment with subsequent recurrence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve High-intensity Focused Ultrasound (HIFU) treatment.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 17, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the service provided was medically necessary. The Plan denied your request. The Plan says there is no 
documentation the enrollee is bed bound. The Plan also says that the care could have been provided by another 
method such as ambulette transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport on December 17, 2021 was medically reasonable and necessary for the patient. Our 
physician reviewer found the documentation does not support that other means of transport (such as stretcher 
van, wheelchair van) were contraindicated for this patient. Our reviewer also found that the documentation 
does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that 
only a fully equipped ambulance could provide for safe transport on December 17, 2021. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on December 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided from December 
1, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you are on a limited income and 
was not provided information about the cost. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay, for 
Medicare-covered therapeutic radiology (radiation therapy) services, a $50 copayment per visit at an in-
network hospital outpatient department or provider-based department of a hospital/clinic. 
 
 
  You have been asked to pay a total of $950 (19 sessions x $50 copayment) for radiation therapy. Radiation 
therapy 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 radiation therapy provided from December 1, 2021, to 
December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an incisional biopsy of eyelid skin including 
lid margin, the destruction of premalignant lesions, a tangential biopsy of skin provided on January 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, an incisional biopsy of eyelid skin including lid margin, the 
destruction of premalignant lesions, a tangential biopsy of skin. You say that you are appealing with supporting 
records. 
 The Plan denied your request. The Plan says the member has no out-of-network benefits, and the services is 
not a participating provider with the Plan.  
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 an office visit, an incisional biopsy of eyelid skin 
including lid margin, the destruction of premalignant lesions, a tangential biopsy of skin provided on January 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 2, 2021, to 
March 4, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnoses of gram-negative sepsis, unspecified (A41.50) and severe sepsis without septic 
shock (R65.20) are not supported in the medical record. The Plan argues that DRG 689 is more appropriate in 
this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 pay for inpatient care billed with DRG 871. Our 
reviewer says that the diagnoses of gram-negative sepsis, unspecified (A41.50) and severe sepsis without septic 
shock (R65.20) are not supported in the medical record for this inpatient admission. Our physician reviewer 
found that the documentation supports an admission for urinary tract infection. While sepsis was documented 
in the progress notes and discharge summary, a diagnosis of sepsis could not be validated. Evidence of a 
dysregulated host response to infection causing life-threatening organ dysfunction represented by a rise in 
Sequential Organ Failure Assessment (SOFA) score greater than or equal to 2 consequent to infection was 
not found within the submitted medical record documentation. The review has determined that the medical 
records did not support the billing of gram-negative sepsis, unspecified (A41.50) and severe sepsis without 
septic shock (R65.20) for the dates in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from March 2, 2021, to March 4, 
2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Radiation Therapy from November 1, 
2021, through November 30, 2021. 
 
You asked the Plan to waive the copayments for Radiation Therapy. You say that the staff told you that you did 
not owe anything. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment per treatment appointment for Radiation Therapy. The claim reflects a $50 copay for each 
visit during the dates of service from November 1, 2021, through November 30, 2021, eight in total, which 
reflects the total $400 copayment amount owed. 
 
 
 
 
  
You have been asked to pay a $50 copayment per treatment appointment for Radiation Therapy. Radiation 
Therapy 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 copayments for Radiation Therapy from November 1, 2021, through 
November 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second complete retroperitoneal ultrasound (76770) 
provided on January 13, 2022. 
 
You asked the Plan to pay for the second complete retroperitoneal ultrasound. You say that the records support 
multiple procedures rendered on this date. The Plan denied your request. The Plan says the documentation 
received does not support that two separate complete retroperitoneal ultrasounds were performed. 
 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 76770 is Ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the second complete retroperitoneal ultrasound. Our reviewer 
says that the additional retroperitoneal ultrasound is not supported in the medical records. Our reviewer found 
while there are two separate reports of a retroperitoneal ultrasound on January 13, 2022, the reports are 
duplicates. Thus, the records only show that one retroperitoneal ultrasound (76700) was done on January 13, 
2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the second complete retroperitoneal ultrasound have not been met. Therefore, 
we decided that the Plan does not have to pay for a second complete retroperitoneal ultrasound (76770) 
provided on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 22, 2020, to 
October 24, 2020, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 195 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 pay for inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that evidence of a dysregulated host response to 
infection causing life-threatening organ dysfunction represented by a rise in Sequential Organ Failure 
Assessment (SOFA) score of greater than or equal to 2 consequent to infection was not found within the 
submitted medical record documentation. The review has determined that the medical records did not support 
the billing of sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from October 22, 2020, to October 24, 
2020, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim reprocessed as in-
network service. The Plan denied your request. The Plan says the rendering and referring providers are both 
OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 11, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) provided 
by a participating provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that your crown fell off. The Plan 
denied your request. The Plan says the benefit limit for the requested dental services has already been met and 
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. The Plan covers one crown 
every five years, and one core build-up per two years. 
 
We looked at the file, and Medicare rules. Evidence was provided to show that D2740 was provided on April 
17, 2019. D2950 was provided on February 13, 2019. Based on this information, we decided that the Plan's 
rules for coverage of a crown and a core build-up have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740), and a core build-up (D2950) provided by a participating provider.