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

 
We decided that the Plan does not have to pay for subsequent nursing facility care 
 
You asked the Plan to pay for nursing facility care. You say that you were injured and treated out of your home 
territory, therefore you did not have access to participating providers. The Plan denied your request. The Plan 
says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nursing facility care have not been met. Specifically, there were no medical records provided in 
this case. Without the medical records, we cannot review to see if the services were urgent/emergent or 
medically necessary. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit, x-ray, arthrocentesis, aspiration and/or injection, and 
Methylprednisolone injection. You say that no referral was obtained because you are OON with the enrollee's 
plan. The Plan denied your request. The Plan says the services were rendered by a non-network provider. The 
Plan also says that the services were not approved in advance. 
 
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 medical services provided on January 8, 2020 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the lower back. 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because magnetic 
resonance imaging has been approved and they would like to do CT on the same day. The Plan denied your 
request. The Plan says there is no order from your physician. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT Scan. Our reviewer says that the 
record does not include an order from your physician. Our physician reviewer found the record does not 
include a covered indication for the CT Scan. 
 
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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the lower back.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you believe that the service was 
medically necessary. The Plan denied your request. The Plan says the service was rendered by a non-contracted 
provider. The Plan also says that prior authorization was not obtained. 
 
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 provided, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from February 25, 2020, to March 2, 2020 by an OON provider. You asked the Plan to pay forthe behavioral health inpatient stay. The Plan denied your request. The Plan says the services were rendered by an OON provider. The Plan also says that prior authorization was not obtained.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 forthe medical services provided from February 25, 2020, to March 2, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 12, 2020. 
 
You asked the Plan to pay for the 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 May 12, 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 by you on May 
12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the reading machine and slim cycle. 
 
You asked the Plan to pre-approve the reading machine and slim cycle. You say that you are totally blind and 
you need the machine to help you read. The Plan denied your request. The Plan says very little clinical 
information was received about your illness. The Plan states your diagnosis is general symptoms and signs. The 
Plan states additional information was requested but not received. The Plan states in order to approve the 
services requested, they need more information, such as provider notes with the medical reason for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the reading machine and slim cycle have not been met. Medical records were not received. More 
documentation is needed to very medical necessity. Therefore, we decided that the Plan does not have to pre-
approve the reading machine and slim cycle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous distraction device (22612, 22867). 
 
You asked the Plan to pre-approve the interspinous distraction device. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says this item is considered experimental and is not covered. 
 
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 interspinous distraction device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the placement of the interspinous distraction device in this application is 
considered experimental. Additional 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 the interspinous distraction device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous distraction device (22612, 22867).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (CPT 99201, CPT 72020) provided 
to you on May 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 chiropractic services (CPT 99201, CPT 72020) provided to you on 
May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (office visit) services, 
mechanical traction services, and electrical stimulation provided by a chiropractor on May 20, 2020. 
 
You asked the Plan to pay for the non-spinal manipulation services. You say that although Medicare does not 
cover chiropractic, your plan does and you feel that the services rendered should be covered. The Plan denied 
your request. The Plan says you are covered only for chiropractic services that are covered by Medicare. This is 
limited to manual manipulation 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 evaluation and management (office visit) services, mechanical 
traction services, and electrical stimulation provided by a chiropractor on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling procedure (D4346) provided on June 
2, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went in for a preventive cleaning and exam. 
You say that the cleaning was billed incorrectly. You also say that you were told it was just a routine cleaning. 
The Plan denied your request. The Plan says that you did not receive a routine cleaning on the date of service. 
The Plan also says that the periodontal scaling procedure is not a covered service. 
 
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 periodontal scaling procedure is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling procedure (D4346) provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 3, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the 
services were billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the drug testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on March 
3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 28, 2019 by an OON provider.You asked the Plan to pay forthe outpatient hospital services. You say that you would like a retro authorization for the outpatient surgery.The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.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 forthe medical services provided on October 28, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the services purchased from September 21, 2019, 
through October 22, 2019, by an out-of-network provider. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
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 reimburse for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The rules say that a total electric hospital bed (E0266) is not covered; the height adjustment feature is a 
convenience feature. Total electric beds will be denied as not reasonable and necessary. Furthermore, the 
providers the bed was both rented from and purchased from are not in-network with the Plan. 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 reimburse for these items/services. Therefore, we decided 
that the Plan does not have to reimburse for the services purchased from September 21, 2019, through October 
22, 2019, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing, physical therapy, and home 
health aide services. 
 
You asked the Plan to pre-approve home health skilled nursing, physical therapy, and home health aide 
services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing, physical 
therapy, and home health aide services. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found that in this case, the documentation doesn?t support that the member requires skilled 
nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does 
not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to 
improve the member?s condition, perform a maintenance program to maintain the patient?s condition and/or 
prevent deterioration. The member has been medically stable without any documented need for skilled nursing 
care and does not have any new functional deficits that would require skilled rehab services.  Furthermore, the 
documentation does not support that the member is home bound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing, physical therapy, and home health aide services 
have not been met. Specifically, the member is not home bound and does not need skilled nursing. Therefore, 
we decided that the Plan does not have to pre-approve home health skilled nursing, physical therapy, and home 
health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2020, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that to deny the Plan's obligation to pay for 
emergency services and admission due to lack of or no notification is in violation of the applicable law and in 
breach of the enrollee's subscription. The Plan denied your request. The Plan says the service was rendered by 
a non-contracted provider. The Plan also says that prior authorization was not obtained. 
 
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 laboratory services provided on June 17, 2020, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone 2.5 MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. This drug is not covered for your condition by Medicare or your health plan. Therefore, we 
decided that the Plan does not have to pre-approve prednisone 2.5 MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services provided 
on August 22, 2019. 
 
You asked the Plan to waive the copayment for outpatient mental health services. You say that you disagree 
with the charges because you canceled the session. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 outpatient mental health services.  
 
The medical records show that you received outpatient mental health services on August 22, 2019. Therefore, 
you are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for outpatient mental health services. Outpatient mental health 
services falls within the outpatient mental health 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 outpatient mental health services provided on August 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on August 6, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the submitted billed code does 
not appropriately reflect the services provided. 
 
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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the submitted documentation does 
not indicate that the physician was present in the member's home. Based on this information, we decided that 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit (99348) provided on August 6, 2019.