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

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections provided on June 27, 
2023, by an OON provider.  
 
You asked the Plan to pay for the injections. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says these services are not covered when received by 
an out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient surgery, including facet joint 
injections is not covered. 
 
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 
items/services 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 paravertebral facet joint injections provided on 
June 27, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Revo Boa socket system (L5999). 
 
You asked the Plan to pre-approve a Revo Boa socket system. You say that the enrollee needs a new prosthetic 
because his current prosthesis is too large which is making him unable to walk safely. The enrollee requires an 
adjustable socket to accommodate daily volume fluctuations due to his diabetes. The Plan denied your request. 
The Plan says Medicare guidance says that experimental items and items that are not shown to be safe and 
effective cannot be covered. 
 
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 a Revo Boa socket system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a right above the knee amputation. Provided medical 
records from the treating/prescribing physician in this case do not document necessity of the Revo Boa socket 
system (L5999) over a standard socket system with sock ply adjustments. 
 
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 Revo Boa socket system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Revo Boa socket system (L5999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS device is 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail trimming and debridement provided on May 25, 
2023. 
 
You asked the Plan to pay for the nail trimming and debridement. 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 nail trimming and 
debridement provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of varicose veins of the lower extremity. 
 
You asked the Plan to pre-approve treatment of varicose veins of the lower extremity. You say that it is 
medically necessary. The Plan denied your request. The Plan says sclerotherapy may be clinically indicated 
when there is no reflux in the saphenous vein is not 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 treatment of varicose veins of the lower 
extremity. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  
 
Our physician reviewer found the documentation does not support the medical necessity of the procedure in question. Review of the medical records could not identify an assessment of lower extremity arterial perfusion 
or a pulse examination. It is not possible to support the appropriateness or medical necessity of any lower 
extremity venous treatment without an assessment of arterial perfusion particularly in you with leg pain. You 
report the pain is preventing you from walking and exercising. Additionally, the results of the lower extremity 
venous duplex demonstrating a patent deep system are not provided. The medical record suggests that you may 
be having symptoms in the distribution of the significantly refluxing small saphenous vein. Therefore, the 
Health Plans unwillingness to cover sclerotherapy in the setting of severe saphenous reflux may be reasonable.  
Based on all the above elements, unable to overturn the Health Plan determination on the basis of medical 
necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of varicose veins of the lower extremity have not been met. 
Therefore, we decided that the Plan does not have to pre-approve treatment of varicose veins of the lower 
extremity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga tablets. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 Farxiga tablets.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing of 15-21 classes (G0482) provided on April 18, 
2023. 
 
You asked the Plan to pay for drug testing of 15-21 classes. You say that these services were medically 
necessary and appropriate. The Plan denied your request. The Plan says it was not medically necessary to test 
this many drug classes definitively. 
 
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 pay for drug testing of 15-21 classes. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not support the necessity of this testing as there was 
no unexpected results from a screening test, nor was there evidence of use or suspicion of use of 15-21 drug 
classes. As this testing is excessive and doesn't meet criteria, it is considered 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 drug testing of 15-21 classes have not been met. Therefore, we decided that the 
Plan does not have to pay for drug testing of 15-21 classes (G0482) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
26, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged 
for a follow-up visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each defibrillator garment rental provided 
on January 28, 2023, to April 28, 2023. 
 
You asked the Plan to waive the coinsurance for each defibrillator garment rental. You say that you were 
unaware of the cost share. 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 and related supplies. 
 
You have been asked to pay 20% coinsurance for each defibrillator garment rental. This item/service falls 
within the durable medical equipment and related supplies 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 amount you owe for each rental is = $669.80 
($3,348.99 allowed amount x 20% = $669.80) The total amount you owe is $2,679.20 ($669.80 x 4 months = 
$2,679.20). Therefore, we decided that the Plan does not have to waive the coinsurance for each defibrillator 
garment rental provided on January 28, 2023, to April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied to blood glucose testing provided by an 
out-of-network (OON) provider on April 1, 2023. 
 
You asked the Plan to waive the deductible applied to the blood glucose testing provided OON. You say that 
there was no payment or denial reason on this claim. You say that this code is separately payable in the 
Medicare guidelines and according to the Medicare fee schedule. You say that it is not bundled or incidental. 
The Plan denied your request. The Plan says the deductible was appropriately applied to the services in dispute. 
 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 most covered services provided 
OON.  
 
The item or service you asked the Plan to waive the deductible for was provided OON. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to most 
covered services provided OON. OON blood glucose testing is not listed as one of the services for which the 
deductible does not apply. This cost sharing is a contractual obligation that had not been met at the time the 
blood glucose testing was received on April 1, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible applied to blood glucose testing provided by an out-of-network (OON) provider on April 
1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on April 11, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on April 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for admission 
to a SNF.  
 
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 pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/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 pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 skilled nursing visits and 8 physical therapy visits.  
 You asked the Plan to pre-approve home health services. You say that you would like reconsideration based on 
the records submitted.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
physical therapy needs. The enrollee is functioning at a level commiserate with a lower level of care.  As such, 
the requested, ongoing, home health skilled nursing and home health physical therapy services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 skilled nursing visits and 8 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 25, 2023, to June 
12, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you do not agree with the denial. 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 April 25, 2023, to June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services that the enrollee requires that are not available at the health care 
setting being offered by the health Plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fludrocortisone Acetate tablets. 
 
You asked the Plan to pre-approve the medication. You say that Fludrocortisone Acetate is medically 
necessary. 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 Fludrocortisone Acetate 
tablets.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden 
variant. You say that you need this testing to see if you can stop using medication without getting blood clots. 
The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
February 17, 2023. 
 
You asked the Plan to pay more for the periodontal maintenance. You say that you received a bill for $218 for 
the dental cleaning and you want to appeal because you were told that the dental provider was in-network. You 
also say that when you called the provider you were told they did not accept your insurance. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodontal maintenance (D4910) 
provided on February 17, 2023.