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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid 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 an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee has an L5-
L1 epidural steroid injection on October 11, 2022, which provided 80% pain relief for 14 days. However, there 
is no documentation of at least 50% of sustained improvement in pain relief or improvement in function 
measured from baseline using SAME scale for at least 3 months from the previous epidural steroid injection. 
Therefore, the enrollee does not meet the LCD 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
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 Ozempic.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on September 
25, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the services provided were 
unprofesstional. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for physical therapy. This item/service falls within the outpatient 
rehabilitation 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 waive the copayment for physical 
therapy provided on September 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for computed tomography (CT) of the 
abdomen and pelvis. provided on August 25, 2023. 
 
You asked the Plan to reduce the coinsurance for computed tomography (CT) of the abdomen and pelvis.. You 
say that you did not know 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for CT scan. 
 
You have been asked to pay 40% coinsurance for computed tomography (CT) of the abdomen and pelvis.. This item/service falls within the CT scan 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 coinsurance for 
computed tomography (CT) of the abdomen and pelvis. provided on August 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar fusion for spinal instability and degenerative 
disc condition, including sacroiliac fusion. 
 
You asked the Plan to pre-approve the lumbar fusion. You say that you have had numbness/tingling and pain in 
your legs for four years. You say you have been doing injections that are not working. The Plan denied your 
request. The Plan says the lumbar fusion is not medically necessary. The Plan says the magnetic resonance 
imaging (MRI) showed no evidence of spondylolisthesis or dynamic instability. 
 
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 lumbar fusion. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found you were being treated for low back pain. However, dynamic flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at the requested surgical level. 
Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative 
instability. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested lumbar fusion at L4-5, 
including sacroiliac fusion 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 lumbar fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the lumbar fusion for spinal instability and degenerative disc condition, including 
sacroiliac fusion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. You say that you have pain in your hip and unable to sleep on this 
side. The Plan denied your request. The Plan says the records do not show a hip exam or at least 3 positive hip 
exams example compression or FABER and no records of considering any intervention or how MRI would 
change management. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation does not support that an 
MRI is necessary or meets criteria for coverage. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the mattress, coded E1399. We decided that the Plan does not have to 
pay for the hospital bed.  
 
You asked the Plan to pay for the hospital bed and mattress billed for date of service July 17, 2023. The Plan 
says that total electric hospital beds are not covered. 
 
We decided that the Plan has to pay for the mattress, coded E1399.  
 
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. 
 
We looked at the file and the rules. The records show that code E1399 was ordered due to an altered sensory 
perception, and difficulty in position changes from left side hemiparesis. The Plan only provided rationale for 
the denial of a total electric hospital bed. The Plan did not show that the criteria for coverage of a pressure 
reducing support surface had not been met. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan 
has to pay for the mattress, coded E1399.  
 
We also decided that the Plan does not have to pay for the hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and the rules. While a total electric hospital bed may be appropriate in this case, neither 
the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay 
for the hospital bed. 
 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 the office visit (99214), and psychotherapy (90836) provided 
on September 27, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that if you see a doctor outside of the United 
States (US) who does not subscribe to Medicare, your plan pays a portion of your claim. You also say that it is 
not fair that the service of a US licensed and practicing US doctor is ineligible for any reimbursement when a 
non-US doctor in another country is eligible. The Plan denied your request. The Plan says the provider in this 
case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a 
provider that has opted out of Medicare. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99214), and psychotherapy (90836) provided on September 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service February 
18, 2023, to March 10, 2023. 
 
You asked the Plan to pay for the billed service. You say that the enrollee was treated for post-surgical edema. 
The Plan denied your request. The Plan says reimbursement is not justified. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code E0675 is not supported in the medical record. Code as E0675 is used in the treatment of 
peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code E0675 billed for dates of service February 18, 2023, to March 10, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic external defibrillator, with integrated 
electrocardiogram analysis (K0606). 
 You asked the Plan to pre-approve a life vest. You say that you are requesting reconsideration of the denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
life vest. 
 
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 life vest. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was approved for a wearable defibrillator (WD) in July 2023, but on a follow-up 
visit, there is no documentation of the enrollee's compliance. In October 2023, the echocardiographic ejection 
fraction was over 50%. The WD is a vest like device worn under the clothing that continuously monitors the 
heart rhythm and automatically delivers an electric shock when ventricular fibrillation or ventricular 
tachycardia is detected. This device is intended to be worn continuously, 24 hours per day, except when the 
wearer is bathing or showering. As such, it would not appear that the enrollee is a candidate for a WD 
according to current guidelines. In summary, authorization and coverage of the WD would not be considered 
medically necessary in this enrollee's clinical management. 
 
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 life vest have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an automatic external defibrillator, with integrated electrocardiogram analysis (K0606).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on September 19, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physicians services 
provided on September 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy. provided on August 09, 2023. 
 
You asked the Plan to pay for chemotherapy.. You say that based on the prior authorization look-up, no 
authorization would be required. 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 chemotherapy. provided 
on August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283 x 10) and an office visit 
provided by a chiropractor (99203) from May 1, 2023, to June 22, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you were told that chiropractic and 
acupuncture services are covered under your plan. The Plan denied your request. The Plan says these 
chiropractic services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation (G0283 x 10) and an office visit provided by a 
chiropractor (99203) from May 1, 2023, to June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extractions (D7210x6). 
 
You asked the Plan to pre-approve the dental extractions (D7210x6). You say that you have been two dentists 
who have advised you need to have these extractions. 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 December 6, 2023, when the Plan 
agreed to pay for one of the extractions. Therefore, we decided that the Plan does not have to pre-approve the 
dental extractions (D7210x6).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on August 10, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the enrollee's medical condition 
required immediate and rapid ambulance transportation that could not have been provided by standard 
automotive ground ambulance. The Plan denied your request. The Plan says the services were medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the enrollee 
presented to a free-standing emergency room with bleeding from a surgical site. The enrollee was confirmed to 
have a hematoma. Transportation for vascular surgery services was medically necessary and reasonable. It 
appears, however, that several closer facilities were available. There is no documentation to explain why the 
enrollee had to be transported to a more distance facility for definitive care. As such, the air ambulance 
transport is not coverable. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on August 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care services provided from April 2, 2021, to April 
14, 2021. 
 
You asked the Plan to pay for the SNF. You say that the services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request.  
 
The Centers for Medicare and Medicaid Services state that any request for appeal must be filed within 60 days 
of the Plans initial determination. The record shows that the Plan issued their determination on May 23, 2021. 
The record also shows that your appeal was received on July 6, 2023. Your request was received more than 60 
days after the Plans initial denial. There is no evidence that you had good cause to file your appeal beyond the 
60-day time limit. Therefore, we decided that the Plan does not have to pay for the SNF care services provided 
from April 2, 2021, to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with limited 
field of view - less than one whole jaw (D0364) provided on August 9, 2023. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that because of severe 
bone loss and gingival recession your general dentist referred you to a periodontist for an evaluation. You also 
say that the periodontist referred you to an endodontist. The Plan denied your request. The Plan says there is no 
coverage for D0364 cone beam computed tomography capture.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
CT capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on August 
9, 2023.