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

 
We decided that the Plan does not have to pre-approve the pain management services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the pain management services. You say that you have submitted medical 
records for review. 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 in 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 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 pain management services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT) with image-guided radiation 
therapy (IGRT) (77499). 
 
You asked the Plan to pre-approve PBT with IGRT. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage 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 PBT with IGRT. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). Several ongoing cooperative groups studies include acceptable dosimetric constraints for a patient undergoing pelvic 
radiation for high-risk prostate cancer. Nothing in the case file suggests that they cannot be met with non-
proton based treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT with IGRT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve proton beam therapy (PBT) with image-guided radiation therapy (IGRT) (77499).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of temporary indwelling bladder catheter 
provided on June 14, 2023. 
 
You asked the Plan to pay for the insertion of temporary indwelling bladder catheter. You say that you asking 
to please review the medical records and process the claim for medical necessity. 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 insertion of 
temporary indwelling bladder catheter provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out-of-network brace provided on April 
15, 2023. 
 
You asked the Plan to waive the deductible for a brace. You say that you are not supposed to be charged this 
much for medical equipment. You refuse to pay for this until it is corrected. 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 $525 deductible which applies to durable medical equipment (DME) 
and related supplies. You have been asked to pay $260.97 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
(DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $525 deductible which applies to durable medical equipment (DME) and related 
supplies.  
 This cost sharing is a contractual obligation that had not been met at the time a brace was received on April 15, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for an out-of-network brace 
provided on April 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic BMP-2 allograft (20930). 
 
You asked the Plan to pre-approve Medtronic BMP-2 allograft. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
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 Medtronic BMP-2 allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found BMP allograft is experimental in the posterior spine. It is not FDA 
approved for use in the posterior spine. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic BMP-2 allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Medtronic BMP-2 allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L4 kyphoplasty. 
 
You asked the Plan to pre-approve the L4 kyphoplasty. You say that your pain level is at a ten and believes you 
are in life-threatening pain. You say the surgery will be the solution. The Plan denied your request. The Plan 
says the kyphoplasty is not medically necessary. The Plan says the back pain is not acute or subacute and the 
magnetic resonance imaging (MRI) documents multifactorial severe significant canal compromise at L4-L5. 
 
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 L4 kyphoplasty. 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 age-related osteoporosis with current pathological fractures. You 
presented with low back, buttocks, hips, and leg pain. The documentation is not evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body height loss, greater 
than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Therefore, the 
enrollee does not meet the criteria for the kyphoplasty at L4. 
 
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 L4 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the L4 kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient T6 and T8 kyphoplasty. 
 
You asked the Plan to pre-approve the outpatient T6 and T8 kyphoplasty. You say that the surgery is medically 
necessary. The Plan denied your request. The Plan says the kyphoplasty is not medically necessary. The Plan 
says the enrollee's fracture is not acute or sub-acute in nature. 
 
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 outpatient T6 and T8 kyphoplasty. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for T6 and T8 compression fractures. The 
enrollee presented with pain in the upper and lower lumbar area that started in April of 2023 from a treadmill 
accident. The documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Additionally, the examination did not corroborate significant deficits 
related to the compression fractures at T6 and T8. Therefore, the requested outpatient T6 and T8 kyphoplasty 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 outpatient T6 and T8 kyphoplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the outpatient T6 and T8 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a positron emission tomography scan and 
the diagnostic agent provided on July 07, 2023. 
 
You asked the Plan to waive the coinsurance for a positron emission tomography scan and the diagnostic agent. 
You say that you disagree with 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 40% 
coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for a positron emission tomography scan and the diagnostic agent. This item/service falls within the out-of-network outpatient diagnostic tests and therapeutic services and 
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. Therefore, we decided that the Plan does not have to waive the coinsurance for a positron emission 
tomography scan and the diagnostic agent provided on July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on May 18, 2023.  
 
You asked the Plan to pay for the outpatient clinic visit. You say that you do not agree with the denial of 
payment for your visit. The Plan denied your request. The Plan says the service was not pre-authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that some in-network medical services are covered only if your doctor or other network provider 
obtains prior authorization from our plan. 
 
  The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit 
provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 25, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
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 chiropractic services provided on May 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy to be provided by the requested provider. 
 
You asked the Plan to pre-approve psychotherapy to be provided by the requested provider. You say that you 
have been in treatment already with this provider and would like to continue. The Plan denied your request. 
The Plan says Marriage & Family Therapists are not Medicare eligible providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy to be provided by 
the requested provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network duplex scan ultrasound 
provided on May 10, 2023. 
 
You asked the Plan to waive the copayment for an in-network duplex scan ultrasound. You say that you feel 
you should not have this bill as you had this done during an annual 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for an in-network duplex scan ultrasound. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network duplex scan ultrasound provided on May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy procedure provided on August 
08, 2023. 
 
You asked the Plan to waive the copayment for the biopsy procedure. You say that you were told that the 
rendering provider that the services would have a lesser copayment of $125. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $200 copayment for the biopsy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the biopsy procedure provided 
on August 08, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray provided on November 10, 2022, 
and the emergency room services provided on June 30, 2023. 
 
You asked the Plan to waive the copayments for the x-ray and the emergency room services. You say that you 
disagree with the copayments. 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 in-network basic radiology at an outpatient hospital. Your contract with the Plan also clearly 
says that you must pay a $90 for emergency services. You can find this information on page 55 of the Plan's 
2023 EOC. 
 
You have been asked to pay $85.21, which is less than the standard copayment for the x-ray provided on 
November 10, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. You have also been asked to pay $77.34, which is less than the standard copayment 
for the emergency services provided on June 30, 2023. 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 copayments for the x-ray provided on 
November 10, 2022, and the emergency room services provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88112, & 88305 billed for date of service 
February 13, 2023. 
 You asked the Plan to pay for procedure code(s) 88112, & 88305. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these codes are included in the facility payment and are 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88112, & 88305. This 
means there is both a professional and technical component for the CPT code(s). In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT code(s) 88112, & 88305. Based 
on this information, we decided that Medicare rules for coverage of procedure code 88112, & 88305 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 88112, & 88305 
billed for date of service February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 12, 2023. 
 
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 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 office visit provided 
on June 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Ubrelvy.   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each cataract surgery provided on July 17, 
2023, to August 03, 2023. 
 
You asked the Plan to reduce the copayment for each cataract surgery. You say that you were told that you 
would only have a $200 copayment for each eye. 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 for outpatient surgery, including services provided at hospital facilities. 
 
You have been asked to pay a $250 copayment for each cataract surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital facilities 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 total amount you owe is $500 ($250 
copayment x 2 surgeries = $500). Therefore, we decided that the Plan does not have to reduce the copayment 
for each cataract surgery provided on July 17, 2023, to August 03, 2023.