Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 medical services provided to the enrollee by an out-of-network provider 
on March 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided by a participating provider on June 29, 2020.You asked the Plan to waive the copayment for emergency care. You say that you were told that if you went to the ER then you wouldn't have to pay for the MRI copayment. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Since emergency room services were provided, the correct copayment has been applied. Emergency care 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 isa 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 emergency care provided by a participating provider on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 medical services provided to the enrollee by an out-of-network provider 
on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on March 31, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
March 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers FDG Positron Emission 
Tomography (PET) scans for either the differential diagnosis of fronto-temporal dementia (FTD) and 
Alzheimer's disease (AD) under specific requirements; OR, its use in a Centers for Medicare & Medicaid 
Services (CMS)-approved practical clinical trial. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the requested PET scan of the brain is medically reasonable and necessary for the enrollee 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) provided April 23, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this documentation verifies the documentation from 
both the enrollee and the provider in order for services to be reimbursed at this time. Please reconsider for 
payment. The Plan denied your request. The Plan says there is no evidence of an established relationship 
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and 
management service and there is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0648) provided April 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of an ankle x-ray provided on May 27, 
2020, billed with CPT code 73600-26-59-52. 
 
You asked the Plan to pay for the x-ray interpretation. You say that this was correctly billed for the services 
rendered. The Plan denied your request. The Plan says the required modifier is missing and the claim cannot be 
paid without it. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill using the correct code and 
anatomic modifiers should be reported when appropriate.  
 
In this case, the ankle x-ray was done on the right side and should be reported with modifier -RT. Therefore, 
we decided that the Plan does not have to pay for the interpretation of an ankle x-ray provided on May 27, 
2020, billed with CPT code 73600-26-59-52.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because 
the home ventilator is medically necessary. The Plan denied your request. The Plan says the home ventilator 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 home ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of CO2 retention while in a stable state.  BiPAP has not 
been tried, with documentation of failure.  The member has a Trilogy ventilator at home but the clinical notes 
indicate she is not using it. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral nutrition rendered from September 25, 2019 to 
October 1, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code B4189 is not supported. 
 
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 code B4189 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any 
strength, 10 to 51 grams of protein - premix. 
 
We find that CPT code B4189 is not supported in the medical record. Specifically, the records show that 
infuvite adult multivitamin infusion was delivered and there is a more appropriate code for these services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the enteral nutrition rendered from September 25, 
2019 to October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea paravertebral facet joint block. You asked the Plan to pre-approvea paravertebral facet joint block. You say that the requested paravertebral facet joint block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested paravertebral facet joint block.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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve a paravertebral facet joint block. Our reviewer says that the enrollee does not meet criteria for the requested paravertebral facet joint block. Our physician reviewer found the enrollee is with back pain. The records show that the enrollee had the same shot is 2019. There is no documentation of greater than 50% functional improvement. More information is needed. Criteria have not been met.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 paravertebral facet joint block have not been met.Therefore, we decided that the Plan does not have to pre-approvea paravertebral facet joint block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 12, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says the orthosis is not supported in the medical records 
received. 
 
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 lumbar-sacral orthosis (L0650). Our 
reviewer says that the orthosis is not medically necessary. Our physician reviewer found Coverage of a lumbar-
sacral orthosis has been requested. At issue is whether the requested orthosis was medically reasonable and 
necessary in this case, according to the coverage criteria established by the LCD. 
 
The available documentation in the case file does not support that the requested lumbar-sacral orthosis was 
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established 
by the LCD. An appropriate history and a physical examination of the back would reasonably be required to 
adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation 
in the case file in regard to the back is limited to 'Thoracolumbar Appearance: normal curvature." The clinical 
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered 
indications 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 the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided 
that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71046) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The requested service was billed on a duplicate claim to one 
previously processed and paid by the Plan. 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 the 
services (CPT 71046) provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued skilled nursing facility (SNF) 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require 
ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 
the last covered date.  The enrollee does not have complex wound care or other ongoing SNF level SN need. 
The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge 
and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment only in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a 
combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require 
the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the acute care hospital on 9/11/20 with systemic inflammatory response syndrome 
(SIRS) with sepsis secondary to pneumonia. His medical history is notable for heart disease and a cerebral 
hemorrhage in July 2020. The enrollee has improved to baseline on antibiotics. The enrollee is receiving PEG 
tube feeds. 
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. The member 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on March 27, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.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 March 27, 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 forthe ambulance services provided by you on March 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 20, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 
services 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 subsequent nursing facility care provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 9, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under your plan unless they are authorized by the Plan before 
the services are provided. 
 
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 
services 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 physician's services provided on January 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction for tooth #21. 
 
You asked the Plan to pre-approve the surgical extraction. The Plan denied your request. The Plan says the 
documentation submitted does not support the code requested. 
 
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. The Plan covers the extraction 
when the services are medically necessary and reasonable.  
 
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 extraction. Our physician reviewer 
found that the documentation provided does not support the need for a surgical extraction of tooth #21. Our 
reviewer says that elevation and/or a forceps extraction would be adequate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extraction have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the surgical extraction for tooth #21.