Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the powered upper extremity orthosis. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this device is considered experimental for the enrollee's condition. More research 
is needed to show safety and efficacy. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the head or brain 
(70450) provided on May 24, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R27.0 has an Excludes1 note in relation to R42. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT scan) of the head or brain (70450) provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
January 23, 2023, through February 21, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted medical records for review. The Plan denied your request. The Plan says a PCD coded as 
E0675 to treat peripheral artery disease is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from January 23, 2023, through February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an OmniGraf genetic testing panel (81479) provided on 
January 9, 2023. 
 
You asked the Plan to pay for OmniGraf testing. You say that you have reported the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that NGS as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, when performed in a CLIA-certified laboratory, when ordered by a treating 
physician, and when all of the requirements listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of OmniGraf testing have not been met. Specifically, Medicare records do not show that the testing at 
issue has FDA approval or clearance. Therefore, we decided that the Plan does not have to pay for an 
OmniGraf genetic testing panel (81479) provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 Sensor. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Dexcom G7 Sensor have been met. Specifically, attempts made to reach your provider to determine medical necessity were unsuccessful.   
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network specialist office visits 
provided on February 21, 2023, to February 22, 2023. 
 
You asked the Plan to waive the copayment for out-of-network specialist office visits. 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 $70 
copayment for out-of-network physician/practitioner services/specialist. 
 
You have been asked to pay a $70 copayment for out-of-network specialist office visits. This item/service falls 
within the out-of-network physician/practitioner services/specialist 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. However, since the allowed amount is less than the 
standard copayment for one visit, you only owe $64.90. The total amount you owe is $134.90 ($70 + $64.90 = 
$134.90). Therefore, we decided that the Plan does not have to waive the copayment for out-of-network 
specialist office visits provided on February 21, 2023, to February 22, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Triluron. 
 You asked the Plan to pre-approve Triluron. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says coverage of the requested drug is subject to their step therapy criteria. The 
Plan says that there is no indication that one of the preferred drugs would be less effective, and/or cause 
adverse effects for the enrollee. 
 
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 Triluron. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found step therapy, as outlined by the Plan, 
requires that one of the preferred viscosupplemental treatments (Orthovisc or Supartz FX) be trialed first. The 
documentation does not outline contraindications or reasons these medications were not considered. The 
documentation does not outline reasons that these medications would likely be less effective and/or likely have 
adverse effects for 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 Triluron have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Triluron.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 18, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 16, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for long 
term acute care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have needs that are consistent with LTACH admission criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the mental health services provided on 
August 04, 2023. 
 
You asked the Plan to waive the coinsurance for the mental health services. You say that you should not be 
held responsible for the coinsurance. 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 50% 
coinsurance for out-of-network outpatient mental health care. 
 
You have been asked to pay 50% coinsurance for the mental health services. This item/service falls within the 
out-of-network 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. The total amount you owe is $85.69 ($171.38 allowed amount x 50% = 
$85.69). Therefore, we decided that the Plan does not have to waive the coinsurance for the mental health 
services provided on August 04, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided on July 19, 2023. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. 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 psychiatric diagnostic 
evaluation provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rehabilitation services provided on April 17, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for rehabilitation services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct. 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 rehabilitation services provided on April 17, 2023, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI), 
brain provided on September 15, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI), brain. You say that 
you cannot afford to pay the copayment for your MRI. 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 $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $195 copayment for the magnetic resonance imaging (MRI), brain. 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 copayment for the magnetic resonance imaging (MRI), brain provided on 
September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an office visit provided on September 26, 
2023. 
 
You asked the Plan to reduce the coinsurance for an office visit. You say that this service should be covered at 
the in-network benefit level. 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 40% 
coinsurance for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 40% coinsurance for an office visit. This item/service falls within the out-of-network physician/practitioner services, including doctors office visits 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. The total amount you owe is $44.27 
($110.67 allowed amount x 40% = $44.27). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for an office visit provided on September 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 20, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic test provided on August 09, 2023. 
 
You asked the Plan to pay for the diagnostic test. You say that the service was 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 the diagnostic test 
provided on August 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically appropriate to admit the 
enrollee to an LTACH. The Plan denied your request. The Plan says the enrollee's medical needs can be met in 
the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not support that the enrollee would benefit from LTACH care at this 
time. The enrollee should only require short-term additional acute care services that can safely be provided at 
the current facility until the enrollee is more appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH 
is not medically necessary as it would not be clinically advantageous. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the enrollee has received optimal non-surgical management or 
been hospitalized with pain, and imaging showed numerous possible etiologies of back pain. 
 
The Plan follows Medicare rules. Medicare rules state that PVA surgery may be covered if certain 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 PVA. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is no trial of bracing for 
fracture care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral lower eyelid blepharoplasty provided on 
December 14, 2022. 
 
You asked the Plan to pay for the bilateral blepharoplasty. You say that you were told no prior authorization 
was required for this procedure. The Plan denied your request. The Plan says this procedure is considered 
cosmetic and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the bilateral blepharoplasty have not been met. The medical records show this was a full cosmetic 
procedure, which is not covered. Therefore, we decided that the Plan does not have to pay for the bilateral 
lower eyelid blepharoplasty provided on December 14, 2022.