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

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on January 11, 2023, to April 11, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 allowed amount for the DME is $199.20. You are being asked to 
pay $39.84 ($199.20 x 20% = $39.84). Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment (DME) provided on January 11, 2023, to April 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says Botox is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Botox. Our reviewer says that treatment 
with Botox is not medically reasonable and necessary in this case. Our physician reviewer found that the 
provided records in this case do not document chronic daily headaches occurring more than 15 days a month 
with a duration of four or more hours for a period of at least 3 months with significant disability due to the 
headaches that have been refractory to standard and usual conventional 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on February 9, 
2023, by an OON provider.  
 
You asked the Plan to pay for the remote monitoring services. You say that the provider must see all patients 
that need care. The Plan denied your request. The Plan says the services were 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 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 remote monitoring services provided on 
February 9, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injections and outpatient observation 
services provided from March 30, 2023, to April 6, 2023. 
 
You asked the Plan to waive the cost share for injections and outpatient observation services. You say that you 
do not understand why the claims are not being paid. 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 and a $295 copayment for outpatient hospital services. 
 
You have been asked to pay $569.62 for injections and outpatient observation services. This total includes 
$228.10 per observation visit, which is less than the standard copayment for outpatient observation services 
($228.10 per visit x 2 visits = $456.20) and $56.71 coinsurance, which is 20% of the allowed amount per 
injection ($283.56 allowed x 20% = $56.71 per injection x 2 injections = $113.42). The injections fall within 
the Medicare Part B prescription drugs benefit category. The observation visits fall within the outpatient 
hospital observation 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 injections and 
outpatient observation services provided from March 30, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services (99152). 
 
You asked the Plan to pre-approve the sedation services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 sedation 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 documentation of unique circumstances of medical necessity. There is no 
documentation provided that this procedure, which can be performed safely without conscious sedation or 
monitored anesthesia care (MAC), cannot be done. The requested anesthesia services are 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 the sedation services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve moderate sedation services (99152).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that you had relief 
with the first injection and would like another. The Plan denied your request. The Plan says that is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say RFA of the sacroiliac joint is not considered 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation of the sacroiliac joint have not been met. Specifically, RFA of the 
sacroiliac joint is not considered medically necessary. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. 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 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 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 laboratory services provided on January 26, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the nerve blocks. 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. 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 nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular nerve blocks.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (1) physical therapy (PT) services (97164 x10). 
 
You asked the Plan to pre-approve the therapy services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the requested services are not medically reasonable and 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's medical condition and therefore, are not medically 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten (1) physical therapy (PT) services (97164 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) and the 
office visit (99202) rendered by the out-of-network (OON) provider from March 1, 2023, through March 27, 
2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatments (98941) and the office visit (99202) 
rendered by the out-of-network (OON) provider from March 1, 2023, through March 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on June 12, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are asking for the medical records 
to 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 skilled nursing facility 
care provided on June 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on June 
30, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. 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 a home or residence visit 
for the evaluation provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for injections performed at an ambulatory 
surgical center provided on March 15, 2022. 
 
You asked the Plan to reduce the copayment for injections performed at an ambulatory surgical center. You say 
that the remaining cost share is a burden to the enrollee and you requesting the claim be reprocessed for 
payment. 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 $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for injections performed at an ambulatory surgical center. This 
item/service falls within the outpatient surgery 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 reduce the 
copayment for injections performed at an ambulatory surgical center provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI provided on June 2, 2023, by an OON provider.  
 
You asked the Plan to pay for an MRI. You say that you are requesting reconsideration of the denied claim. 
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 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 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 MRI provided on June 2, 2023, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for practitioner services/office visits provided from 
January 12, 2023, to April 12, 2023. 
 
You asked the Plan to reimburse you for the practitioner services/office visits. You say that these services meet 
the Medicare requirements. The Plan denied your request. The Plan says the provider is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
practitioner services/office visits provided from January 12, 2023, to April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on April 14, 
2023. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you should only be 
responsible for a $20 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 record shows you received services from an urgent care center. Therefore, we decided 
that the Plan does not have to reduce the copayment for an urgent care visit provided on April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor and segmental pneumatic 
appliance to be provided by an OON provider.  
 
You asked the Plan to pre-approve the pneumatic compressor and segmental pneumatic appliance. You say that 
you are requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says 
these items are available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the pneumatic compressor and segmental pneumatic appliance to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 11, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of 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 the laboratory service 
provided on April 11, 2023.