Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the regadenoson injection, the medical 
supplies, and the cardiovascular stress test provided on February 21, 2023. 
 
You asked the Plan to waive the cost share for the injection, the medical supplies, and the stress test. You say 
that these services should be billed under the positron emission tomography scan. 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-covered Part B drugs. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for each Medicare-covered medical supply. Your contract with the Plan also clearly says that 
you must pay a $30 copayment for Medicare-covered non-radiological diagnostic services. 
 
You have been asked to pay 49.08, which is 20% coinsurance of the allowed amount for the injection ($245.40 
allowed amount x 20% = $49.08). This item/service falls within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay $208.09, which is 20% coinsurance of the allowed amount for the 
medical supplies ($1,040.46 allowed amount x 20% = 208.09). 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. 
 
You have also been asked to pay a $30 copayment for the stress test. 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 cost share for the regadenoson injection, the medical supplies, and the cardiovascular stress test 
provided on February 21, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 20, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for psychotherapy. You say that services were medically necessary and provided in 
good faith. The Plan denied your request. The Plan says the 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 psychotherapy provided on December 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 9, 2023, by an OON 
provider.  You asked the Plan to pay for the home visit. You say that you are appealing with supporting medical records. 
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 Plan contract also says that the enrollee's POS benefit only 
applies to non-Medicare covered dental services. 
 
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 home visit provided on March 9, 2023, by an 
OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits (G0151). 
 You asked the Plan to pre-approve home health services. You say that the services are 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
available records the enrollee appears to have improved with therapy to the point of being able to ambulate and 
transfer with contact guard assistance/supervision. After 86 physical therapy treatments, records do not support 
that the complexity of the enrollee's conditions are such that the skills of a professional therapist are required to 
achieve further improvement in the enrollee's symptoms or functional status. Further utilization of the home 
exercise program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home health physical therapy visits (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on September 13, 
2022, by an OON provider.  
 
You asked the Plan to pay for the subsequent hospital care. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 item/service 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 the item/service. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care provided on September 13, 2022, 
by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on January 13, 2023, to January 30, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you presented 
your insurance card and was not advised the provider was out-of-network. 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 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services 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 $80 for physical therapy visits ($20 per visit x 4 visits 
= $80). Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy 
(PT) visit provided on January 13, 2023, to January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T). 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 high dose rate electronic brachytherapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the NCCN clinical practice guidelines describe this procedure as 
having insufficient evidence supporting long-term efficacy or safety compared to standard treatment options for 
your condition. A current literature review also showed insufficient long-term data. Therefore, without sufficient support made for this request, the high dose rate electronic brachytherapy will be considered not 
medically necessary 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 high dose rate electronic brachytherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (0394T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for mammography on February 28, 2023.  
 
You asked the Plan to waive the deductible for mammography. You say that you were not aware that 
deductible applies to outpatient services at hospitals. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time mammography was received on February 28, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for mammography on February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 pre-approve Prednisone.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system (E1399). 
 
You asked the Plan to pre-approve a Volara system. You say that you disagree with the denial and request 
reconsideration due to medical necessity. The Plan denied your request. The Plan says Medicare states that 
intrapulmonary percussive ventilators such as the Volara device have not been demonstrated to be reasonable 
and necessary in the home setting. 
 
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 Volara system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a diagnosis of bronchiectasis and mycobacterium avium-intracellular infection. The 
Volara system provides internal oscillation (intrapulmonary percussive) therapy to help mobilize pulmonary 
secretions. Provided medical records and review of the current peer-reviewed medical literature do not 
document that use of the Volara system/internal oscillation (intrapulmonary percussive) therapy has been 
shown in controlled studies to result in long term health benefits in patients with bronchiectasis and 
mycobacterium avium-intracellular infection.  
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system (E1399).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a diagnostic right SI joint injection (27096).  
 
You asked the Plan to pre-approve an SI joint injection. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a diagnostic SIJI is covered when all the criteria listed 
in the Medicare section 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 an SI joint injection. Our reviewer says 
that the injection is medically necessary. Our physician reviewer found that the enrollee has a normal 
neurological exam and has symptoms which may be related to right SI joint. He has already had a Medrol dose 
pack with temporary relief of symptoms but slowly the symptoms have recurred. The request for an SI joint 
injection is reasonable and a clinical evaluation afterward will aid in an ultimate diagnosis and therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SI joint injection have been met. Therefore, we decided that the Plan has to 
pre-approve a diagnostic right SI joint injection (27096).   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says non-Medicare 
covered preventive dental services, such as cleanings, fillings, and crowns, are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to see your cancer provider and it 
is over the 50-mile radius. The Plan denied your request. The Plan says you are requesting an additional 7.3 
miles for a total of 57.3 miles and your benefit only allows 50 miles. The Plan also says you have exceeded 
your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bydureon Bcise. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 pre-approve Bydureon Bcise.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of the plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from an out-of-network provider, the plan may deny coverage and the enrollee will 
be responsible for the entire cost. 
 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 an office visit provided on March 17, 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 a home visit provided on March 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says the 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 a home visit provided on March 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease (DJD) or foraminal stenosis. The cause of back 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (64628 and 64629).