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

 
We decided that the Plan does not have to waive the copayment for the neurostimulator procedure provided on 
February 06, 2023. 
 
You asked the Plan to waive the copayment for the neurostimulator procedure. You say that you were told 
there would be a $0 copayment, and all they did was change the batteries. 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 $85 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $85 copayment for the neurostimulator procedure. This item/service falls within 
the outpatient surgery provided at an outpatient hospital 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 neurostimulator procedure provided on February 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy supplies provided on January 07, 
2023. 
 
You asked the Plan to pay for home infusion therapy supplies. You say that this was medically necessary and 
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 home infusion therapy 
supplies provided on January 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment and care planning services provided on March 
01, 2023. 
 
You asked the Plan to pay for assessment and care planning services. You say that the provider was not 
responsible for obtaining authorization. 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 assessment and care 
planning services provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease services provided on December 01, 
2022. 
 
You asked the Plan to pay for end-stage renal disease services. You say that you are requesting the submitted 
documentation be reviewed. 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 end-stage renal disease 
services provided on December 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography provided on November 03, 2022. 
 
You asked the Plan to pay for mammography. You say that you are requesting the submitted documentation be 
reviewed. 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 mammography provided 
on November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 27, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. We depend on the facility to get this authorization. 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 nursing facility visit 
provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system.  
You asked the Plan to pre-approve a CGM system. The Plan denied your request. The Plan says this request 
does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a CGM system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve 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 your benefit for the requested item or 
service has already 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 your benefit for the requested item or service was exhausted on date of service August 12, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the requested genicular artery 
embolization is medically necessary.  The Plan denied your request. The Plan says the requested genicular 
artery embolization 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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not medically necessary.  Our physician 
reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the left knee. She 
presented with left knee pain that is aching and daily. The pain is rated a 4/10 on the visual analog scale (VAS). 
She reports crepitus on active motion of the left knee. She has morning stiffness in the left knee. The range of motion is decreased secondary to pain. The left knee exam reveals a varus angulation deformity. Left knee 
crepitus is present with palpation of the left knee as well as pain on palpation. There is pain to palpation of the 
medial joint line. There is decreased range of motion secondary to pain. There is an altered gait. Valgus stress 
testing and grinding are positive. 
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. While the studies are noted to be promising, 
further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than 
standard treatments for knee osteoarthritis. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested genicular artery 
embolization, in this case, is 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on January 30, 2023. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that this is supported in the records. 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 electrocardiogram 
(ECG) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown-porcelain fused to high noble metal for 
tooth number 18 (D2750) and a core buildup, including any pins when required for tooth number 18 (D2950). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit.  
 
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 are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pre-approve a dental crown-porcelain fused to high noble 
metal for tooth number 18 (D2750) and a core buildup, including any pins when required for tooth number 18 
(D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) mask 
provided on September 14, 2022. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) mask. You say that you want to be 
reimbursed for this item. The in-network provider did not have the item you needed. 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 continuous positive 
airway pressure (CPAP) mask provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planing provided on February 13, 2023. 
 
You asked the Plan to pay for advance care planing. You say that you say that the provider had no prior 
knowledge of which patients he would be requeire to see. 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 advance care planing 
provided on February 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine stress test provided on 
February 01, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine stress test. You say that this was ordered 
by your provider, and cardiovascular screenings have a $0 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 $325 
copayment for outpatient diagnostic radiology. 
 
You have been asked to pay a $325 copayment for the nuclear medicine stress test. This item/service falls 
within the outpatient diagnostic radiology 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 records show a diagnostic test was provided, and the screening 
copayment does not apply. Therefore, we decided that the Plan does not have to waive the copayment for the 
nuclear medicine stress test provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prolia injection provided on November 
29, 2022. 
 
You asked the Plan to waive the coinsurance for the prolia injection. You say that you cannot afford the shot. 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the prolia injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $289.03 ($1,445.14 allowed amount x 20% = $289.03). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the prolia injection provided on 
November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from February 24, 2022, to March 25, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility care needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from February 24, 2022, to March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for foot x-rays provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for foot x-rays. You say that you do not think you should have to 
pay for this service. 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 $15 
copayment for x-rays performed at a specialist office. 
 
You have been asked to pay a $15 copayment for foot x-rays. This item/service falls within the x-rays 
performed at a specialist office 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 
foot x-rays provided on January 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits (G0151, G0299). 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as you 
disagree with the denial and they are medically necessary The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
 
  The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health physical therapy visits (G0151, G0299).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 31, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services are 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 laboratory services 
provided on January 31, 2023.