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

 
We decided that the Plan does not have to pay for physician's services provided on June 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a speech generating device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted information does not show evidence of laryngotomy, radical neck surgery, radiotherapy in the neck area and/or evidence of a permanently inoperable larynx.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is conflicting information within the records provided for review. There was a request for coverage that listed a diagnosis of ALS. However, you have also been diagnosed with Alzheimer's Dementia. There were no medical records provided to support either of these diagnoses or to permit an independent determination of which is more appropriate. Based on the speech therapist's notes, other forms to address speech have been considered and ruled out. However, it should be noted that there has not been a documented history of speech therapy (per the claims history). There is the possibility that if you indeed has ALS, such a device would assist in your communication. However, if you have dementia, such a device would likely not be beneficial given the progressive nature of such a condition.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a speech generating device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided by a 
participating provider on March 5, 2020, to March 9, 2020. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this was because of an 
emergency. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $550 
copayment per day for days 1-3. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $550 copayment per day for days 1-3. There is a $0 copayment for additional 
days for an inpatient stay. The total amount you are being asked to pay is $1,650 ($550 x 3 days = $1,650). An 
inpatient stay falls within the inpatient hospital care/in-network 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 inpatient stay provided by a participating provider on March 5, 2020, to March 
9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally- invasive posterior decompression (MILD) 
procedure of the spine. 
 
You asked the Plan to pre-approve a MILD procedure. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services.  
 
We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression or commercially known as the mild procedure will be covered when provided in an approved 
clinical study. The file does not show that the enrollee is enrolled in an approved clinical study. Therefore, we 
decided that the Plan does not have to pre-approve a minimally-invasive posterior decompression (MILD) 
procedure of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid for the 
enrollee due to leg swelling and venous insufficiency. The Plan denied your request. The Plan says these 
stockings are noncovered under the surgical benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray services (73610) provided on June 27, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, Medicare guidelines state that modifiers LT and RT are to be used 
to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and 
ovaries. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals 
use the appropriate -RT or -LT modifier to identify which of the paired organs was operated upon. In this case, 
procedure code 73610 is an x-ray of the ankle; complete, minimum of 3 views, which is not considered to be a 
paired organ. The Plan has not provided any supporting documentation showing that procedure code 73610 is 
only payable if billed with modifiers 50, LT, or RT. Therefore, we decided that the Plan has to pay for the x-ray 
services (73610) provided on June 27, 2020.  
 
 
 
 
 
 
 
 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee tested positive for COVID, 
and cannot be admitted to a lower level of care. The Plan denied your request. The Plan says the enrollee's 
complex medical needs are being met in the current acute setting. 
 
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 physician 
reviewer found that the enrollee presented to the acute care hospital for the treatment of COVID-19. There is 
no documentation provided requiring admission to a LTACH. The enrollee still requires acute hospital level of 
care services and is receiving appropriate care at the present facility. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amputation services billed to the enrollee for date of service 
June 8, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the medical records submitted do not include sufficient documentation of an amputation, finger 
or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement 
flaps (V-Y, hood) being performed on June 8, 2020 as the flap was not adequately documented, therefore, full 
description of this procedure cannot be verified. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for amputation services billed to the enrollee for date 
of service June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician visits, 
lab monitoring, and managed electrolyte replacement. The Plan denied your request. The Plan says the enrollee 
does not need daily doctor visits, specialized nursing, or continued acute hospital care for more than 25 days. 
 
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 physician 
reviewer found that the enrollee presented to the emergency department for hypoxia. The enrollee still requires 
acute hospital level of care services, and is receiving appropriate care at the present facility. The enrollee does 
not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 12, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the operative report does not include documentation of radical resection of tumor 5 cm or less 
of normal tissue. Therefore CPT 27615 cannot be verified.  We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not 
been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the 
enrollee on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that you are in pain and need the buildup. The 
Plan denied your request. The Plan says core buildup is not a covered benefit. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electromyogram and nerve conduction study to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON electromyogram and nerve conduction study. You say that  The 
Plan denied your request. The Plan says the requested services are available with the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an electromyogram and nerve conduction study to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 11, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration for bone grafting. You say that the enrollee has 
failed conservative treatment. The Plan denied your request. The Plan says this 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 bone marrow aspiration for bone 
grafting. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found bone marrow aspiration is experimental. More research is needed to 
show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration for bone grafting have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirteen (13) physical therapy visits to an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. You say that you would like to have this appeal approved prior 
to operation. The Plan denied your request. The Plan says it is not medically necessary for you to go to 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 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 
thirteen (13) physical therapy visits to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee has not completed the full course of treatment in the 
hospital. The Plan says that it is not reasonable to expect that the enrollee would be able to safely participate in 
an intensive rehab program, nor fully benefit from the intensity of services in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that this enrollee can participate in a rehabilitation 
therapy program at an IRF level of care at this time. There is not a reasonable expectation that the enrollee will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot do anything on your own. The Plan 
denied your request. The Plan says your request for an IRF stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do require physical therapy and occupational therapy services, but based on the medical records provided 
you do not require an intensive inpatient rehabilitation therapy program. Our physician reviewer also found that 
there is no documentation that you require the intensive rehabilitation therapy program provided in an IRF. 
Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.