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

 
We decided that the Plan does not have to pay for bilateral screening mammography, including computer-aided 
detection (CAD) when performed (77067) and screening digital breast tomosynthesis, bilateral (List separately 
in addition to code for primary procedure) (77063) provided on November 10, 2022, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the diagnostic service. You say that you do not understand why the cost of your 
mammogram was denied. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 bilateral screening mammography, including 
computer-aided detection (CAD) when performed (77067) and screening digital breast tomosynthesis, bilateral 
(List separately in addition to code for primary procedure) (77063) provided on November 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve the medication. You say that Cequa is needed by the enrollee. 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 Cequa.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CTA of the abdominal arteries. 
 
You asked the Plan to pre-approve a CTA of the abdominal arteries. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that 
a CTA of the abdominal arteries is not medically necessary. 
 
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 a CTA of the abdominal arteries. Our 
reviewer says that a CTA of the abdominal arteries is medically necessary. Our reviewer found that an annual 
CTA for monitoring an abdominal aortic aneurysm, 4.0-4.4 cm in diameter, in a female above 65 years of age 
is reasonable and recommended by the guidelines. 
 
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 CTA of the abdominal arteries have been met. Therefore, we decided that the 
Plan has to pre-approve a CTA of the abdominal arteries.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that Orthovisc is not medically necessary; however, no medical 
records were received for review. Without medical records, a determination based on medical necessity cannot 
be supported. Therefore, we decided that the Plan has to pre-approve Orthovisc.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
January 20, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that you do not believe 
this was a diagnostic procedure. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for diagnostic hearing services. 
 
You have been asked to pay a $15 copayment for the diagnostic hearing exam. This item/service falls within 
the diagnostic hearing 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. According to Medicare the hearing exam (code 92557) is considered a 
diagnostic procedure. Therefore, we decided that the Plan does not have to waive the copayment for the 
diagnostic hearing exam provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on August 12, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the services provided. 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 August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on November 
03, 2022. 
 
You asked the Plan to pay for an office visit, and related services. 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, and 
related services provided on November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for corticosteroid injection provided on 
December 06, 2022. 
 
You asked the Plan to reduce the copayment for corticosteroid injection. You say that the injection cannot be 
done in the providers office, it must be done in the hospital. 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 $100 
copayment for outpatient hospital services. 
 
You have been asked to pay a $100 copayment for corticosteroid injection. This item/service falls within the 
outpatient hospital 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. Therefore, we decided that the Plan does not have to reduce the copayment for 
corticosteroid injection provided on December 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cyst removal provided on January 19, 
2023. 
 
You asked the Plan to waive the copayment for the cyst removal. You say that you already made a copayment 
to the facility. 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 in-network outpatient surgery, including physician services. 
 
You have been asked to pay a $40 copayment for the cyst removal. This item/service falls within the in-
network outpatient surgery, including physician 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 this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the cyst removal provided on January 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from December 26, 2022, to January 24, 
2023. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from December 26, 2022, to January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on 
February 6, 2023. 
 
You asked the Plan to pay for procedure code 93970. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this test was ordered as part of a preoperative 
testing/screening. 
 The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for this service would have been included under the facility claim. Payment to you for this 
service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay 
for the duplex scan of extremity veins (93970) provided on February 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 1, 2023, to January 13, 
2023. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from January 1, 2023, to January 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote device evaluation provided on 
February 17, 2023. 
 
You asked the Plan to waive the copayment for the remote device evaluation. You say that this was to check 
the device, not your health, so you should not have to pay. 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 $10 
copayment for in-network diagnostic tests. 
 
You have been asked to pay a $10 copayment for the remote device evaluation. This item/service falls within 
the in-network diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the remote device evaluation provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4), an upper partial denture (D5213), and a lower partial denture (D5214). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says these dental items/services are not covered.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items/services are not 
among those covered under this benefit.  
  
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or 
more teeth per quadrant (D4341 x 4), an upper partial denture (D5213), and a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on November 18, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amalgam and crown (D2150, D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your annual $1,000 dental benefit 
maximum allowance for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 22, 2023. 
Therefore, we decided that the Plan does not have to pre-approve an amalgam and crown (D2150, D2740).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a referral to an out-of-network gastroenterologist for a double 
balloon endoscopy. 
 
You asked the Plan to pre-approve these services. You say that the in-network providers do not perform the 
procedure.  The Plan denied your request. The Plan says that the services are available from network providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services are available from network providers; however, 
there is no documentation to confirm that there is a network provider who can perform the double balloon 
endoscopy. This information was requested from the Plan, but a response was not received. Therefore, we 
decided that the Plan has to pre-approve a referral to an out-of-network gastroenterologist for a double balloon 
endoscopy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on January 26, 2022. 
 
You asked the Plan to pay for injections. 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 injections provided on 
January 26, 2022.