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

 
We decided that the Plan does not have to pay for tattooing, intradermal introduction of insoluble opaque 
pigments to correct color defects of skin (11920) received on July 25, 2023. 
 
You asked the Plan to pay for tattooing. You say that the procedure was not cosmetic, and it should be covered. 
The Plan denied your request. The Plan says coverage does not provide for procedures performed for cosmetic 
purposes unless the enrollee's condition resulted from an accidental injury. 
 
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 tattooing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided is insufficient to document the medical necessity of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tattooing have not been met. Therefore, we decided that the Plan does not have 
to pay for tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin 
(11920) received on July 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on June 26, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the service should be 
covered since it was a medical emergency. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 26, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on June 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage provided on April 14, 2023. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that the mileage was medically 
necessary. The Plan denied your request. The Plan says mileage beyond the closest available facility cannot be 
billed to Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance miles beyond the closest available 
facility cannot be billed to Medicare. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for non-covered ambulance mileage provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement services provided on August 
08, 2023. 
 
You asked the Plan to pay for a home visit, and debridement services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit, and 
debridement services provided on August 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 28, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the ambulance crew was 
able to stabilize your sugar level without needing to go to the hospital. The Plan denied your request. The Plan 
says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on July 28, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided from September 3, 2023, to 
September 4, 2023. 
 You asked the Plan to pay for the hospital care. You say that the enrollee was not on hospice during this period. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital care provided from September 3, 2023, to September 
4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show a detailed history of why the study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee has lumbar 
radiculopathy. The record provided does not document the presence of red flag signs or symptoms or the 
failure of a conservative course of treatment. The requested service is not medically necessary and reasonable 
for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication for a 
long time. You also say the enrollee has done very well with it and needs to continue taking this medication. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 Rinvoq.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and preparation of a saliva sample for 
laboratory diagnostic testing (D0417) provided on April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this would be covered under 
your medical benefit. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
collection and preparation of a saliva sample for laboratory diagnostic testing (D0417) provided on April 13, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the arm. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says additional imaging is not medically 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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found medical necessity of the requested CT scan 
of the right shoulder has not been established in the submitted records. The request cannot be approved at this 
time. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the arm.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is needed due to abnormal findings on a 
previous scan. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the patient had lung opacities seen on CT scan 
during an acute episode in the hospital and follow-up imaging was recommended to exclude underlying lesion, 
which is medically necessary and reasonable. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the thorax.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150) 
provided on August 8, 2023.  
 
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 pay for a self-administered drug (A9270) provided on July 27, 2023. 
 
You asked the Plan to pay for the medication. You say that this should be covered. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
   
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 a self-administered drug 
(A9270) provided on July 27, 2023.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel allowance for laboratory services provided on April 
13, 2023. 
 You asked the Plan to pay for the travel allowance. You say that the travel logs support payment of the claim. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for travel allowance for laboratory services provided on April 13, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on July 31, 
2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary due to the enrollee's condition at the time of transport. The Plan denied your request. The Plan says 
the services were not medically necessary. 
 
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-emergent transport services. Our 
reviewer says that the transportation services were not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transportation were contraindicated. Transfer by an 
ambulance was not medically reasonable or 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 the non-emergent transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent transport services provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 2, 2023. 
  
You asked the Plan to pay for the refraction. You say that you have an eye condition, and it is medically 
necessary to have this treatment. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 one refraction every calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a refraction on February 27, 2023, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction 
provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on March 23, 2023. 
 
You asked the Plan to pay for the office visit . You say that you need this service for the macular degeneration 
in your right eye. The Plan denied your request. The Plan says that the service is a medical code that is not 
covered under the routine vision benefit. 
 
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 this service. 
 
We looked at the file and the Plan's rules. Specifically, the Plan improperly applied the routine eye benefits for 
an active, medical office visit code.  Based on this information, we decided that the Plan's rules for coverage of 
the office visit have been met. Therefore, we decided that the Plan has to pay for the office visit provided on 
March 23, 2023. 
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloMap Heart (81595) testing provided on August 2, 
2022. 
 
You asked the Plan to pay for the AlloMap Heart (81595) testing. You say that the provided AlloMap Heart 
testing was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria 
for the provided AlloMap Heart testing. 
 
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 pay for the AlloMap Heart (81595) testing. Our 
reviewer says that the enrollee did not meet criteria for the provided AlloMap Heart testing. Our physician 
reviewer found the AlloSure test is described as a blood test designed to detect the presence of donor cell-free 
DNA in the recipients blood as a measure of the probability of rejection in heart transplant recipients. The 
enrollee had a heart transplant in 2022. There is no documentation provided to support the basis for the testing. 
As such, there is no evidence to support its role in this enrollee's clinical management. In summary, the testing 
was not considered reasonable or 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 the AlloMap Heart (81595) testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the AlloMap Heart (81595) testing provided on August 2, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergent transport services provided on August 2, 2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary as the enrollee had abnormal posture, unspecified lack of coordination, repeated falls and required a 
medical attendant to safely transport them. The Plan denied your request. The Plan says that the documentation 
does not show that the ambulance transport was medically necessary. 
 
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-emergent transport services. Our 
reviewer says that the transport services were medically necessary. Our physician reviewer found the 
documentation supports contraindication of other means of transport. The ambulance transfer was medically 
reasonable and necessary for the safety of the enrollee. 
 
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-emergent transport services have been met. Therefore, we decided that 
the Plan has to pay for the non-emergent transport services provided on August 2, 2023.  
 
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.