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

We decided that the Plan does not have to pay for the office outpatient visit (99204) provided on by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the member needs to speak with the primary care doctor in order to obtain these 
services. Since the recommended provider is out-of-network and the setting is not at the primary care office, 
the denial is upheld on appeal. 
 
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 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. The 
requested weight loss services are not being requested in the primary care setting and are not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the office outpatient visit (99204) provided on 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 traction, electrical stimulation, and massage services 
performed by a chiropractor on June 10, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says excluded 
from coverage is any service other than manual manipulation to treat subluxation of the spine. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the traction, electrical stimulation, and massage services performed by a 
chiropractor on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's 
plan requires utilization of network providers, and authorization for certain 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 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 on February 20, 2020 by an out of network 
(OON) 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 enrollee has made progress with the limited 
therapies she received in the SNF. With the intensive therapies that can be provided at an IRF, she can make 
greater gains to return to her independent/self-sufficient abilities. The Plan denied your request. The Plan says 
based on Medicare guidelines, the enrollee does not meet the requirements for approval of IRF. The Plan 
reviewed the records and they show the enrollee was admitted to the hospital and now is at a skilled nursing 
facility receiving therapy. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sepsis, GI bleed, anemia and encephalopathy. She was transferred to skilled nursing facility 
on October 3, 2020. There are no medical problems requiring inpatient management. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record does document a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation 
that this patient 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) 
provided on June 24, 2020. 
 
You asked the Plan to pay the full amount for the dental item. You say that you have proof of 100% coverage 
for dentures. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500 for 
dental services. The Plan says that the dentures were paid 100% up to the annual maximum 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 and dentures are a covered service, the 
annual maximum benefit of $1,500 has been reached. 
 
Date of Service     Plan Paid     Benefit Remaining     Your Responsibility 
1/8/2020              $61              $1,439                      $0 
2/5/2020              $472            $967                         $0 
6/24/2020            $967            $0                             $183 
TOTAL:                $1,500         $0                            $183 
 
Therefore, we decided that the Plan does not have to pay more for the complete upper denture (D5110) 
provided on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the doctor has indicated that the enrollee continues to require the IRF admission. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require 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.  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. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on April 5, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that due to the date of service being past 
03/01/2020 which under location of Telemedicine does not require authorization for payment of services 
rendered. Requesting reprocessing of the claim. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 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 outpatient office visit (99205) provided on 
April 5, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer (22869, 22870, C1821). 
 
You asked the Plan to pre-approve a Vertiflex interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has 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 a Vertiflex interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device 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 a Vertiflex interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Vertiflex interspinous spacer (22869, 22870, C1821).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiological diagnostic services provided 
by a participating hospital on April 22, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this should be billed for being done 
in the doctor's office. 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 $100 
copayment for outpatient diagnostic tests/radiological services.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests/radiological services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
radiological diagnostic services provided by a participating hospital on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion nursing visit, initial 2 hour (99602) home 
infusion nursing visit, additional hour (99601) provided January 13, 2020 to January 17, 2020. 
 
You asked the Plan to pay for the home infusion services. You say that the claims mentioned denied incorrectly 
stating invalid procedure code. You feel this denial is incorrect. Please process and pay claim accordingly. The 
Plan denied your request. The Plan says invalid procedure code for this service. 
 
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, 99602 and 99601 has a status code of "I". Medicare guidance says status code "I" is not valid for 
Medicare purposes. Medicare uses another code for reporting of and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of the home infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion nursing visit, initial 2 hour (99602) 
home infusion nursing visit, additional hour (99601) provided January 13, 2020 to January 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are considered experimental/investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure is considered investigational at this time. It has not been studied in any 
high level prospective or RCT against other emptying procedures and has not been shown to be clearly durable 
for long term results. 
 
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 pre-approve gastric peroral endoscopic myotomy (G-POEM).
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that you require that are not already available and 
covered at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Transfer to a lower level of care may be considered soon. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria has not been met. 
 
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 
dental services to be provided by an out of network (OON) provider.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; second level (CPT Code 64491) and injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; single level (CPT Code 64490). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not 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 the services. Our physician reviewer 
found the meets the criteria of the LCD.  The request is medically reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-
approve (CPT Code 64491) and (CPT Code 64490).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $20 copayments charged for physical therapy provided 
from July 15, 2020 to July 31, 2020 by an outpatient rehabilitation facility. 
 
You asked the Plan to waive these copayments. You say that the pulmonary rehabilitation places were closed 
due to Covid. You stated (to the Plan and to a letter to our office) that you had no choice but to go to the 
physical therapy provider for this service. You stated that these copayments should be waived because this was 
the only provider available. The Plan denied your request. The Plan says the order from your physician was for 
therapy due to a difficulty in walking secondary to COPD. The therapy is further defined on the signed order as 
a Pulmonary physical therapy program, which still constitutes a physical therapy program, not just pulmonary 
rehabilitation. Physical therapy applies a $20 copayment per physical therapy session, and the records support 
the claims submitted for physical therapy by your provider, not solely for pulmonary therapy.  
 
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 $20 
copayment for each physical therapy visit. These copayments were charged based on the orders written by your 
physician and the services provided. 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 $20 copayments charged for pulmonary rehab 
provided from July 15, 2020 to July 31, 2020 by an outpatient rehabilitation facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 
physical therapy services to be provided by an out of network (OON) provider.