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

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the records provided did not include evidence that 
the enrollee has a smoking history of at least 20 pack-years and without this documentation, we are unable to 
establish that the Medicare criteria for coverage are met. Therefore, we decided that the Plan does not have to 
pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 
1, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on March 1, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care. provided on September 15, 2023. 
 
You asked the Plan to pay for initial nursing facility care.. You say that you are appealing based on medical 
necessity. 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 initial nursing facility 
care. provided on September 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case there was no documentation 
that the member met diagnostic requirements for either let alone both AD and FTD. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0442 and 96160 provided on August 21, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes G0442 and 96160. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 procedure codes G0442 and 96160 provided on 
August 21, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carbon ultralight rollator. 
 
You asked the Plan to pre-approve a carbon ultralight rollator. You say that the enrollee's present rollator is not 
manageable. The Plan denied your request. The Plan says the enrollee has had a rollator provided within the 
past 5 years. 
 
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 carbon ultralight rollator have been met. Specifically, records supporting the medical necessity of the request have not been provided. Therefore, 
we decided that the Plan does not have to pre-approve a carbon ultralight rollator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scans of the neck and thorax. 
 
You asked the Plan to pre-approve the CT scans. You say that the imaging is needed to fully evaluate the extent 
of the enrollee's oral cancer. 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 scans. Our reviewer says that 
the service is medically necessary. Our physician reviewer found as demonstrated in the NCCN guidelines for 
follow-up recommendation of oral cancer, imaging with CT with IV contrast is reasonable to for continued 
follow-up for surveillance of these patients. 
 
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 scans have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) scans of the neck and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repair of congenital heart defect (93580). 
 
You asked the Plan to pre-approve a repair of congenital heart defect. You say that the requested service 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 repair of congenital heart defect. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that clinical studies have shown significantly higher peri-procedural complications in 
older age groups; hence, the guidelines do not recommend patent foramen ovale (PFO) closure in patients over 
age 60. As such, the guidelines would not support the need for a PFO closure device.  
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 repair of congenital heart defect have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a repair of congenital heart defect (93580).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (92553, 92555, 92567, 
G0463) provided on April 13, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you were in the process of 
relocating to another state and you thought your policy was now associated with the new region. The Plan 
denied your request. The Plan says self-referred specialist visits are not covered by the plan as this is a health 
maintenance organization (HMO) and all care must be coordinated by your primary care provider. 
 
 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 a hospital outpatient clinic visit (92553, 92555, 
92567, G0463) provided on April 13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent nursing facility care. provided on July 12, 2023. 
 
You asked the Plan to pay for Subsequent nursing facility care.. You say that you are appealing this denial. 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. provided on July 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services. provided on September 08, 2023, 
to September 27, 2023. 
 
You asked the Plan to pay for physical therapy services.. You say that the referring provider is in-network. 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 physical therapy 
services. provided on September 08, 2023, to September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumococcal vaccination provided on June 13, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pneumococcal vaccination provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide OON 
care. 
 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 pneumococcal vaccination provided on June 
13, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on July 29, 2022. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. 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 immunization services 
provided on July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of a lower extremity. 
 
You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says 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 not medically necessary. Our physician reviewer found there are no clear recent physical examination 
findings showing evidence to support the right knee deformity or other objective information which might 
warrant advanced imaging of the right knee 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 a lower extremity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nitroglycerin sublingual provided on September 24, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was medically necessary.  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 nitroglycerin sublingual 
provided on September 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on August 08, 2023. 
 
You asked the Plan to pay for physicians services. You say that the 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 physicians services 
provided on August 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
February 18, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on February 
18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liver biopsy, CT scan and chemotherapy services 
provided on May 26, 2023, to July 19, 2023. 
 
You asked the Plan to pay for the biopsy of liver, CT scan and chemotherapy service. You say that you have 
not received any information on why your insurance did not cover the billed services. 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 20% 
coinsurance for Medicare Part B covered chemotherapy drugs and other Part B covered drugs. Also, enrollees 
must pay a $150 copayment at outpatient facilities for diagnostic radiology services and $150 copayment per 
visit for outpatient surgery at a hospital outpatient facility. 
 
 
You have been asked to pay a total of $856.39 for the liver biopsy, CT scan and chemotherapy services. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
May 26, 2023 Liver biopsy $321.20 $150 $150 
June 9-June 30, 
2023 
Chemotherapy 
services 
$3,066.94 20% $613.38 
July 19, 2023 CT scan $93.01 $150 $93.01 
TOTAL:    $856.39 
 
These items/services fall within the Medicare Part B prescription drugs, outpatient diagnostic tests and 
therapeutic services and supplies and outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 pay for the liver 
biopsy, CT scan and chemotherapy services provided on May 26, 2023, to July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve VIA Disc allograft intervertebral disc augmentation procedure. You say that 
this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the VIA Disc allograft intervertebral disc augmentation in the setting of chronic low back pain have not been 
demonstrated in the peer-reviewed literature. 
 
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 VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found VIA disc allograft is experimental for back 
pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc 
augmentation procedure (0627T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 24, 2023. 
 
You asked the Plan to pay for the 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 pay for the self-administered drugs 
provided on June 24, 2023.