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

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (SIJ RFA). 
 
You asked the Plan to pre-approve SIJ RFA. 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 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 SIJ RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental due to the wide variation in efficacy reported in the 
peer reviewed literature. Therefore, the request is deemed 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 SIJ RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sacroiliac joint radiofrequency ablation (SIJ RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service June 14, 
2023.   
You asked the Plan to pay for procedure code 88377. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 13 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
correctly coded and were medically necessary. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88377 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88377 billed for date of service June 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the psychiatric diagnostic evaluation 
provided by an out-of-network provider on January 25, 2023. 
 
You asked the Plan to waive the deductible for the psychiatric diagnostic evaluation. You say that you do not 
agree with the cost sharing. 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 out-of-network outpatient mental 
health care. 
 
 
 
 
 You have been asked to pay a $209.61 deductible for the psychiatric diagnostic evaluation. The item or service 
you asked the Plan to waive the deductible 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 
outpatient mental health care. This cost sharing is a contractual obligation that had not been met at the time the 
psychiatric diagnostic evaluation was provided on January 25, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for the psychiatric diagnostic evaluation provided by an out-of-network 
provider on January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 14, 2023, 
to April 05, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe you shouldn't 
be responsible for. 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 $250 
copayment per day for days 1-3; $0 per each additional day for inpatient hospital care. For the first three days 
there is a $250 copayment per day. 3 x $250 = $750. Therefore, reuslts in total cost sharing amount of $750. 
 
 
 You have been asked to pay a $250 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay on March 14, 2023, to April 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a venous procedure provided on December 08, 2022. 
 
You asked the Plan to pay for a venous procedure. You say that this was medically necessary and 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 a venous procedure 
provided on December 08, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided from June 1, 2021, to June 10, 
2021. 
 
You asked the Plan to pay for hospice services. You say that the claims have been corrected several times and 
should not be denied for untimely filing. The Plan denied your request. The Plan says the corrected claim was 
not submitted within 12 months from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a corrected claim for hospice services was not filed until April 6, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for hospice services provided from June 1, 2021, to June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an infection in your gum. The Plan 
denied your request. The Plan says your benefit 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 June 8, 2023, and June 
23, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a Yeti water bottle purchased on July 27, 2023. 
 
You asked the Plan to reimburse for a Yeti water bottle. You say that the benefit does not say that the warm or 
cold water bottle does not say it cannot be a drinkware type. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a Yeti water 
bottle is an OTC item. Therefore, we decided that the Plan does not have to reimburse for a Yeti water bottle 
purchased on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 6, 2022, 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 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 office visit provided on December 6, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on April 28, 2023, to 
June 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the service provided. 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 skilled nursing facility care provided on April 28, 
2023, to June 19, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were pushed 
to go to urgent care but feel the services were unnecessary. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care 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 an emergency room 
(ER) visit provided on June 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthotic. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the MyoPro orthotic. Our reviewer says 
that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical record supports the enrollee's individual need for the requested orthosis. 
 
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 MyoPro orthotic have been met. Therefore, we decided that the Plan has to 
pre-approve the MyoPro orthotic (L8702).  
 
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 pre-approve the intraosseous ablation. 
 
You asked the Plan to pre-approve the intraosseous ablation. You say that the enrollee has tried and failed 
conservative treatment without any relief. The Plan denied your request. The Plan says the intraosseous 
ablation 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 intraosseous ablation. Our reviewer 
says that the intraosseous ablation is not medically necessary. Our physician reviewer found that the 
intraosseous ablation is the subject of ongoing clinical trials and is considered an experimental 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 the intraosseous ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intraosseous ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that the testing is not available through any other 
entitiy. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided from May 2, 2023, to May 26, 
2023, by an out-of-network (OON) provider.  
  You asked the Plan to pay for the home health visit. You say that the facility is responsible to obtain prior 
authorization and the services provided were medically necessary. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the services 
rendered were not urgent or emergent. 
 
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 home health visit provided from May 2, 2023, 
to May 26, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says a PET scan is 
not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee was not suspected of 
having either AD or FTD and their neuropsychological testing suggested Hashimoto's Encephalitis. The 
enrollee also was found to have abnormal thyroid function which can also impact memory. Therefore, the 
enrollee does not meet the NCD coverage criteria.  
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Accu-Chek blood glucose meter. 
 
You asked the Plan to pre-approve the blood glucose meter. You say that the enrollee has tried the OneTouch 
products and is having difficulty with it. The Plan denied your request. The Plan says only the preferred brands 
products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a blood glucose meter. Therefore, we decided that the Plan does not have to pre-approve an Accu-Chek 
blood glucose meter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010), surgical extractions (D7210), 
sinus augmentations (D7951), and a bone replacement graft for ridge preservation (D7953), provided on May 
17, 2023. 
 
You asked the Plan to pay for D6010, D7210, D7951, and D7953. You say that someone from customer 
service told you these services were covered. The Plan denied your request. The Plan says the rendered dental 
services are not covered benefits. 
 
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 an endosteal implant (D6010), surgical extractions (D7210), sinus augmentations (D7951), and a bone 
replacement graft for ridge preservation (D7953), provided on May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you were told the CGM would be covered, and you 
cannot keep sticking yourself. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the documentation from your physician indicates that 
you do not use insulin or have a history of problematic hypoglycemia. Based on this information, we decided 
that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on June 06, 2023, to June 
27, 2023. 
 
You asked the Plan to pay for the chiropractic 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 chiropractic services 
provided on June 06, 2023, to June 27, 2023.