Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation 
provided on December 12, 2022, and the family psychotherapy provided on December 19, 2022, by an out-of-
network provider. 
 
You asked the Plan to waive the copayment for the psychiatric diagnostic evaluation, and the family 
psychotherapy. You say that you think that these services should be covered. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out-of-network mental health services provided in all places of service. 
 
 You have been asked to pay a $80 copayment for the psychiatric diagnostic evaluation, and the family 
psychotherapy because the Plan made an exception to process these services at the in-network benefit level. 
These items/services fall within the outpatient mental health 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 the psychiatric diagnostic evaluation provided on December 12, 2022, and the 
family psychotherapy provided on December 19, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan, thorax, low dose for lung cancer provided on 
March 20, 2023, by an OON provider.  
 
You asked the Plan to pay for CT scan, thorax, low dose for lung cancer. You say that your provider told you to 
schedule the test and it would be covered. The Plan denied your request. The Plan says the service was denied 
as it requires prior authorization, and one was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. 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 CT scan, thorax, low dose for lung cancer 
provided on March 20, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care and Initial nursing facility 
care provided on December 15, 2022, to December 27, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care and Initial nursing facility care. You say that the 
services should be covered. 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 subsequent nursing 
facility care and Initial nursing facility care provided on December 15, 2022, to December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a silicone (or equal) breast prosthesis (L8030). 
 
You asked the Plan to pre-approve a silicone (or equal) breast prosthesis. You say that you have asymmetry in 
your breasts and need this item. The Plan denied your request. The Plan says there is no indication you have 
had a masectomy or a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that a silicone (or equal) breast prosthesis is covered 
for certain diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a silicone (or equal) breast prosthesis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a silicone (or equal) breast prosthesis (L8030).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac-joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac-joint injection. You say that sacroiliac-joint injection is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sacroiliac-joint injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of four (4) weeks of non-invasive, conservative 
therapy (e.g., exercise, physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs [NSAIDs] and 
analgesics) and ongoing, active participation in a rehabilitative/therapeutic exercise program.  
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 sacroiliac-joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac-joint injection (27096).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from December 7, 2022, to 
December 11, 2022, at the original DRG billed. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis is supported by the physician's 
documentation. The Plan denied your request. The Plan says that the documentation does not support the 
principal diagnosis. 
 
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. 
 
We looked at the file and the rules. The Plan denied the billed services as the documentation did not support 
diagnosis code A41.9. The Plan has not provided the medical records used in their decision to deny services. 
The case file does not show that the Plan was unable to obtain medical records despite multiple attempts. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the inpatient hospital services 
provided from December 7, 2022, to December 11, 2022, at the original DRG billed.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that you need the injections for pain and mobility. The 
Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that that 
Synvisc is not medically necessary. Our physician reviewer found that you have not tried and failed the Plans 
required drugs Euflexxa, Durolane, Supratz-FX and Gelsyn-3. Also, there is no indication that the Plans 
required drugs would likely be less effective or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 27, 2023, to March 2, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were discharged 
too early.  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 $225 
copayment per day, for days 1 to 6 and a $0 copayment per day, for days 7 to 90 for each medically necessary 
covered inpatient stay.  
 
 You have been asked to pay a $225 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $675 ($225 copayment x 3 days = $675). You have not been charged for any 
additional days. 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 an inpatient hospital stay provided from February 27, 2023, to March 
2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an x-ray 
provided on December 29, 2022. 
 
You asked the Plan to waive the copayments for a specialist office visit and an x-ray. You say that you did not 
need the x-ray. 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 $50 
copayment for each Medicare-covered specialist office visit. Your contract with the Plan also clearly says that 
you must pay a $45 copayment for each Medicare-covered x-ray. 
 
You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $45 copayment for the x-ray. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a specialist 
office visit and an x-ray provided on December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an appeal for the denial of 
rehabilitation so you can regain your strength and some independence. The Plan denied your request. The Plan 
says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation. You do require significant assistance with mobility and 
performing your daily activities and may benefit from physical and occupational therapies.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider was listed as in-network. The 
Plan denied your request. The Plan says out-of-network care is not covered but a one-time exception has been 
made and now your benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows an exception has been made to cover out-of-network services and now your benefit was exhausted when 
the Plan reprocessed your claim and paid $3,000 for dental services. Therefore, we decided that the Plan does 
not have to pay more for the dental services provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that the denial is 
inconsistent with benefits provided to the patient. The Plan denied your request. The Plan says that the 
procedure is considered experimental, investigational, or unproven. 
 
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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is no magnetic resonance 
imaging (MRI) showing only modic changes without facet degenerative joint disease or foraminal stenosis. The 
cause of pain is not clear. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was 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 the laboratory services provided on November 19, 
2022, by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography/computed tomography (PET/CT) 
dotatate scan (78814). 
 
You asked the Plan to pre-approve a PET/CT dotatate scan. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET/CT dotatate scan. Our reviewer 
says that the requested service is medically necessary and reasonable for the enrollee at this time. Our 
physician reviewer found PET dotatate scans have been shown to aid in the imaging and identification of 
meningioma, and in conjunction with magnetic resonance imaging aids in radiation target volume delineation 
and evaluating treatment response. 
 
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 PET/CT dotatate scan have been met. Therefore, we decided that the Plan has 
to pre-approve a positron emission tomography/computed tomography (PET/CT) dotatate scan (78814).  
 
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 waive the copayment for a total hip arthroplasty provided on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you got this surgery 
approved in advance. 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 50% 
coinsurance for outpatient surgery/out-of-network.  
 
You have been asked to pay less than a 50% coinsurance of the allowed amount for an outpatient surgery. The 
total allowed amount is $11,929.12. The total amount you are being asked to pay is $5,350.41, which is less 
than your 50 % coinsurance amount of $5,368.10 ($11,929.12 x 50% = $5,368.10). This item/service falls within the outpatient surgery/out-of-network benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a total hip arthroplasty provided on September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment K0553 billed for date of service 
October 24, 2022. 
 You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an appropriate diagnosis was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code K0553 was billed with primary diagnosis code E08.21, diabetes mellitus due to 
underlying condition with diabetic nephropathy. There is a code first note for diagnosis code group E08, 
indicating the underlying condition should be listed first. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for durable medical equipment K0553 billed for date of service October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitor (CGM) 
and supply allowance. 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that you need this for your 
diabetes. The Plan denied your request. The Plan says you do not meet criteria to require a CGM to properly 
manage your diabetes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM and supply allowance. Our 
reviewer says that the CGM and supply allowance is not medically necessary. Our physician reviewer found 
coverage for CGM include insulin use or low blood glucose sugar. As morning blood glucose sugar are still 
around 200 in May and a A1C was 11% in March you may soon require insulin. However, now you are not 
using insulin as of the last office visit note provided and no low blood glucose sugar is noted nor would they be 
expected on just Ozempic and Metformin. Coverage for criteria for CGM are not met 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 CGM and supply allowance. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitor (CGM) and supply 
allowance.