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

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. 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 an office visit provided on January 19, 2023, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97035, 97110, 97140, G0283) 
provided on August 4, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service was provided out-of-network and was not emergent or pre-
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 chiropractic services (97035, 97110, 97140, 
G0283) provided on August 4, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on 
March 15, 2023. 
 
You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you do not think that 
there is a copayment 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 30% 
coinsurance for out-of-network annual wellness visits. 
 
You have been asked to pay 30% coinsurance for an annual wellness visit. This item/service falls within the 
out-of-network annual wellness 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 you owe is $52.50 ($175 allowed amount x 30% = $52.50). Therefore, 
we decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on 
March 15, 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 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 appears to be currently unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD) provided on February 01, 
2023. 
 
You asked the Plan to pay for end-stage renal disease (ESRD). 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 end-stage renal disease 
(ESRD) provided on February 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 26, 2022. 
 
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 October 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trans perineal placement of biodegradable material 
periprostatic single or multiple injections (55874). 
 
You asked the Plan to pre-approve trans perineal placement of biodegradable material periprostatic single or 
multiple injections. 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 follows Medicare rules. Medicare rules say that prostate rectal spacers are covered when specific 
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 trans perineal placement of 
biodegradable material periprostatic single or multiple injections. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the prostate volume in this case is above the level required 
in the LCD.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trans perineal placement of biodegradable material periprostatic single or 
multiple injections have not been met. Therefore, we decided that the Plan does not have to pre-approve trans 
perineal placement of biodegradable material periprostatic single or multiple injections (55874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a remote interrogation device evaluation 
provided on March 16, 2023. 
 
You asked the Plan to waive the copayment for a remote interrogation device evaluation. You say that you do 
not think that there is a copayment 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 $35 
copayment for in-network Medicarecovered physician specialist services. 
 
You have been asked to pay a $35 copayment for a remote interrogation device evaluation. This item/service 
falls within the in-network Medicarecovered physician specialist 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. However, since the allowed amount is 
less than the standard copayment, you only owe $25.08. Therefore, we decided that the Plan does not have to 
waive the copayment for a remote interrogation device evaluation provided on March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to fuse multiple levels in the front of the neck 
(20930, 20936, 22551, 22552, 22846, 22853). 
 
You asked the Plan to pre-approve services to fuse multiple levels in the front of the neck. 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 services to fuse multiple levels in the 
front of the neck. 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 correlation between magnetic resonance 
imaging (MRI) showing nerve or cord compression and physical exam.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services to fuse multiple levels in the front of the neck have not been met. 
Therefore, we decided that the Plan does not have to pre-approve services to fuse multiple levels in the front of 
the neck (20930, 20936, 22551, 22552, 22846, 22853).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. 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 office visit provided on February 1, 2023, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 14, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung 
cancer screening received on December 9, 2022. 
 
You asked the Plan to pay for the requested LDCT scan. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the service is only covered once a year. 
 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 you received a LDCT screening on June 9, 2022, 
meaning that the benefit for 2022 was exhausted. Therefore, we decided that the Plan does not have to pay for a 
low dose computed tomography (LDCT) scan for lung cancer screening received on December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical procedure on the esophagus provided on March 
07, 2023. 
 
You asked the Plan to pay for a surgical procedure on the esophagus. You say that you would like the denial of 
this service to be reconsidered. 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 surgical procedure on 
the esophagus provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2022. 
 
You asked the Plan to pay for an office visit. 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 office visit provided 
on December 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tobramycin nebulizer solution. 
 
You asked the Plan to pre-approve Tobramycin nebulizer solution. 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 Tobramycin nebulizer solution have been met. Specifically, medical records were requested but not received. Medical necessity cannot be 
established without this documentation. Therefore, we decided that the Plan does not have to pre-approve 
Tobramycin nebulizer solution.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the medical notes provided by the enrollee's treating 
practitioner does not indicate that the enrollee meets the criteria above for a HFCWOD. In addition, during a 
peer-to-peer review with the treating practitioner, she indicated that the enrollee does not have a diagnosis of 
cystic fibrosis, bronchiectasis, or neuromuscular disease. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic 
obstructive pulmonary disease, interstitial pulmonary fibrosis and infection with mycobacterium avium 
complex with a cough and thick pulmonary secretions. Provided records in this case do not document the 
enrollee has cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency 
chest wall oscillation device may be covered. There is no qualifying diagnosis for a HFCWOD documented in 
this case.  
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on November 21, 2022. 
 
You asked the Plan to pay for ultrasound. 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 ultrasound provided on 
November 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sleep study provided on March 01, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for sleep study. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 sleep study provided on March 01, 2023, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.