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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spine services 
(72156, 72157, 72158). 
 
You asked the Plan to pre-approve MRI of spine services (72156, 72157, 72158). You say that these services 
are medically necessary. The Plan denied your request. The Plan says the services requested do not meet 
medical necessity criteria. 
 
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 MRI of spine services (72156, 72157, 
72158). Our reviewer says that the services requested are not medically reasonable or necessary. Our physician 
reviewer found in this case, there is insufficient clinical information to approve the requested study. This 
information would include results of a detailed physical examination (with neurological exam) relevant to the 
imaging procedure requested. Imaging is not supported without results of a physical exam that show a reason 
for imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of spine services (72156, 72157, 72158) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spine services 
(72156, 72157, 72158).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services you received on August 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your doctor does not go to the closest 
hospital. The Plan denied your request. The Plan says that this is not the nearest facility. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the ambulance services by a contract provider. The file does not show that the Plan 
provided notice that the ambulance services would not be covered. Under Medicare rules, this means the 
ambulance services is considered approved by the Plan. You were taken to the facility that your doctor be at 
with the reasonable expectation that the transportation would be covered under your plan. Therefore, we 
decided that the Plan has to pay for the ambulance services you received on August 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 5, 2020, to June 
25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
rendering facility is also out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on June 5, 2020, 
to June 25, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that your doctor depends upon the hospital staff 
to obtain authorization. The Plan denied your request. The Plan says you did not request 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. 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 the physician services provided by an out of 
network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for various services provided to the enrollee on May 5, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
HCPCS J3490: 
 
dantrolene sodium 
 
HCPCS E0766: 
 
Electrical stimulation device used for cancer treatment, includes all accessories, any type 
 
HCPCS E0780: 
 
Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours 
 
HCPCS E1399: 
 
durable medical equipment, miscellaneous 
 
CPT 82948: 
 
glucose; blood, reagent strip 
 
HCPCS S1015: 
 
IV tubing extension set 
 
HCPCS S8301: 
 
Infection control supplies, not otherwise specified 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation did not indicate that dantrolene sodium (HCPCS J3490) was administered; therefore, this 
service cannot be verified. The documentation does not include proof that the enrollee received an electrical 
stimulation device (E0766). There is no physician order to dispense this equipment. Therefore, this service 
cannot be verified as performed. The procedure report does not include sufficient documentation to verify that 
an infusion pump (E0780) was used during the procedure. Therefore, this equipment cannot be verified. The 
documentation did not include a valid physician order to verify E1399. The procedure does not indicate that 
blood sugars were performed during procedure, therefore this item (CPT 82948) cannot be verified.  
 
Additionally, HCPCS S1015 and HCPCS S8301 have a status indicator of "I" which means that they are not 
valid for Medicare purposes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for various services provided to the enrollee on May 5, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home hemodialysis services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. Medicare rules say that staff assisted home dialysis is not covered. 
 
We looked at the file and Medicare rules. The services at issue are staff assisted home dialysis. These services 
are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve home 
hemodialysis services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a non-covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on May 22, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained by the rendering facility or 
physician. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient services provided on May 22, 2020, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided to the enrollee on March 13, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was received past the allowed twelve-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 22, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for mental health services provided to the enrollee on March 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met in a less intensive setting of care. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she 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 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic activities (97530) received on 
August 24, 2020. 
 
You asked the Plan to waive the copayment for therapeutic activities. You said that you had met your out-of-
pocket maximum for the 2020 benefit year. The Plan denied your request. The Plan says the claim was 
processed correctly per your plan?s policy. 
 
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 $40 
copayment for physical therapy.  
 
You have been asked to pay a $40 copayment for therapeutic activities. This falls under the Outpatient 
Rehabilitation Services benefit category. This means 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 therapeutic activities 
(97530) received on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xigduo XR 10-1000 mg tablet 
 
You asked the Plan to pre-approve Xigduo. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this is not a medical necessity denial. Given our current information, this drug is 
not covered for your condition by Medicare Part B. 
 
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 Xigduo XR 10-1000 mg 
tablet  
 
Benefits for Xigduo 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the patient can be provided therapies at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-one injection (J7326). 
 
You asked the Plan to pre-approve Gel-one. You say that this service is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-one. Our reviewer says that the 
service is not medically necessary and reasonable. Our physician reviewer found this 59-year-old morbidly 
obese man has bilateral osteoarthritis of his knees. He has tried topical Voltaren, Melocicam, CBD oil and 
intra-articular steroids without significant relief. The patient has not tried either Monovisc or Orthovisc and 
does not have a contra-indication to either of these medications. Therefore, there does not appear any reason to 
make an exception to step therapy at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one injection (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 27, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
You say that it is the facilities responsibility to obtain prior authorization. The Plan denied your request. The 
Plan says prior authorization was not obtained. The Plan says that the rendering facility did not obtain 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on August 27, 2020, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on June 3, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that at the time the in network provider was 
not accepting patients. The Plan denied your request. The Plan says you did not have a referral or authorization 
for the chiropractic services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. You did not have a referral. 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 the chiropractic services provided on 
June 3, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
July 2, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 2, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or 
facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) 
provided by an out of network (OON) provider.