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

 
We decided that the Plan does not have to pre-approve a suction assisted lipectomy. 
 
You asked the Plan to pre-approve lipectomy. You say that the record indicates that the enrollee has 
lipodystrophy in the form of dorsocervical fat pad. The record provided does not document concerning 
characteristics or change in the lesion that warrant removal. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The Plan denied your 
request. The Plan says the medical 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 lipectomy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found are in 24/7 chronic pain and have limited mobility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lipectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a suction assisted lipectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the power wheelchair. You say that the process has already taken a long 
time and you want to appeal this decision. The Plan denied your request. The Plan says there are in-network 
providers who can provide the power wheelchair. 
 
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 power wheelchair 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 services provided on February 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. 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 the laboratory services provided on February 1, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you would like to continue seeing this 
provider. The Plan denied your request. The Plan says there are in-network providers who can provide this 
service. 
 
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 office visit to be provided 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 March 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the denial with supporting 
documentation. 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 March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the endoscopic injection of implant 
material provided by an out-of-network provider on March 6, 2023. 
 
You asked the Plan to waive the cost sharing for the endoscopic injection. You say that you would like the 
claim to be processed as in-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. Your 
contract with the Plan says that there is a $1000 deductible which applies to ambulatory surgical center (ASC) 
services, and that you must pay a $125 copayment after your $1000 plan deductible, for each Medicarecovered 
outpatient surgery at an ambulatory surgical center. 
 You have been asked to pay a $810.88 deductible, and a $125 copayment for the endoscopic injection. The 
item or service you asked the Plan to waive the cost sharing for was provided by an out-of-network provider. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible 
which applies to ambulatory surgical center (ASC) services. This cost sharing is a contractual obligation that 
had not been met at the time the endoscopic injection was provided on March 6, 2023. Therefore, we decided 
that the Plan does not have to waive the cost sharing for the endoscopic injection of implant material provided 
by an out-of-network provider on March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care billed for dates of service September 2, 
2022, to September 28, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a corrected 
claim was not submitted. 
 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, the claim submitted is inconsistent to the itemized bill. 
The file shows that the Plan made multiple attempts to correct the discrepancies with no success. Based on the 
information provided, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient care billed for dates of service September 2, 2022, 
to September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chronic care management and monitoring services to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve chronic care management and monitoring services. You say that the service 
is medically necessary. The Plan denied your request. The Plan says this service can be provided in-network. 
 
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 
chronic care management and monitoring services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 surface resin anterior (D2332) provided on February 9, 
2023. 
 
You asked the Plan to pay for 3 surface resin anterior. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 3 surface 
resin anterior (D2332) provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on March 6, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you did not know that 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. Your 
contract with the Plan says that there is a $650 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 
 
 You have been asked $179.81 toward your deductible for the office visit. The item or service you asked the 
Plan to waive the deductible for falls within the physician/practitioner services, including doctor's office visits 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $650 
deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is 
a contractual obligation that had not been met at the time the office visit was received on March 6, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser surgery provided on January 15, 2023, to January 
19, 2023. 
 
You asked the Plan to pay for the laser surgery. You say that you are requesting reconsideration. 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 laser surgery 
provided on January 15, 2023, to January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing table. 
 
You asked the Plan to pre-approve standing table. You say that this will be able to help the enrollee get in a 
standing position. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a standing table.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections provided on April 04, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you would like to appeal this 
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 Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injections. This item/service falls within the 
Medicare Part B drugs 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 coinsurance for the drug 
injections provided on April 04, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (95811). 
 
You asked the Plan to pre-approve an attended polysomnography. The Plan denied your request. The Plan says 
a supervised in-facility sleep study and CPAP titration is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a follow-up polysomnography or a cardio-respiratory 
sleep study is indicated for the conditions listed in the Medicare rules section of this letter. 
 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 attended polysomnography. Our 
reviewer says that an attended polysomnography with positive airway pressure titration is not medically 
necessary. Our physician reviewer found the enrollee has an established diagnosis of obstructive sleep apnea 
(OSA) and has been on CPAP.  According to the notes of the visit on March 23, 2023, the enrollee's CPAP 
device was recalled, and the purpose of the sleep study is to get a replacement device. Our reviewer found that 
there is no indication that the enrollee was having problems with CPAP or sleep symptoms prior to the device 
recall. Our physician reviewer also found that a sleep study is not necessary to replace a CPAP device, unless 
there have been major changes in body weight or other medical changes that would warrant a reinvestigation of 
the OSA diagnosis. 
 
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 attended polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attended polysomnography (95811).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows a comprehensive gene panel was provided. The medical records from the treating physician 
does not show that the test was ordered for treatment of a specific medical problem. The test at issue in this 
appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service February 
28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 7, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the ambulance services. 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 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 ambulance services provided on January 7, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 services 
provided on September 22, 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 you are requesting a fast appeal for the denial of an 
IRF admission. The Plan denied your request. The Plan says IRF care is not considered medically reasonable 
and necessary based on Medicare guidelines. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
rehabilitation needs can be provided at a lower intensity and alternate setting such as in a skilled nursing 
facility.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that walking is causing pain to go down your leg and 
into your foot. You say that due to the pain you are unable to lay on your left side. The Plan denied your 
request. The Plan says a sacroiliac joint injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has done a home 
exercise program and had tired different medications such as Hydrocodone, Tylenol, and Cyclobenzaprine. 
However, there is no documentation of various proactive diagnostic maneuvers. The LCD requires three tests 
need to be documented. Therefore, the request is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the pneumatic compression device (E0675), provided on 
August 31, 2022, through September 19, 2022. 
 
You asked the Plan  to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have  to 
pay for the pneumatic compression device (E0675), provided on August 31, 2022, through September 19, 
2022.