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

 
We decided that the Plan does not have to pay for the radiological examination (X-Ray) chest (71045), 
transportation of portable X-Ray equipment (R0070) and set up of portable X-Ray equipment (Q0092) 
provided on January 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for X-Ray of chest with transport and set up of the portable X-Ray equipment. You 
say that you do not believe you are required to absorb the cost of providing care to patients that have no ability 
to request prior authorization for medically necessary care. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 radiological examination (X-Ray) chest 
(71045), transportation of portable X-Ray equipment (R0070) and set up of portable X-Ray equipment (Q0092) 
provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee would greatly benefit from continuing 
care. The Plan denied your request. The Plan says there are network providers available. 
 
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 
a referral to an out-of-network urologist.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve HPC; allogeneic transplantation per donor (CPT Code 38240). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the documentation reviewed from the medical record does not indicate that the 
patient will be treated within such a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the service is necessary. Allogeneic transplant is an option. 
 
 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve HPC; allogeneic transplantation per donor (CPT Code 38240).  
 
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 hospital care (99223) provided on May 20, 2020. 
 
You asked the Plan to pay for the hospital care. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says CPT code 99223 was denied because 
it was reported with another evaluation and management service on the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223 is not supported in the record. Specifically, if more than one evaluation and 
management service is provided on the same day to the same member by the same physician, only one 
evaluation and management service may be reported. The record indicates that another evaluation and 
management service was billed by this physician on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for hospital care (99223) provided on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 March 12, 2020, by an out of network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 3, 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. 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 the services provided on 
February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rotator cuff surgery. 
 
You asked the Plan to pre-approve rotator cuff surgery. 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. 
 
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 rotator cuff surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is not enough information present. The documentation does not include any 
imaging studies to support the enrollee's diagnosis. Therefore, the enrollee does not meet criteria for the 
requested 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 rotator cuff surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve rotator cuff surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would regain a maximum 
prior level of functioning and continue multidisciplinary approach to care. The Plan denied your request. The 
Plan says the enrollee does not to see a doctor every day, or need specialized nursing or respiratory care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include intravenous antibiotics, surveillance laboratory studies, wound management, and therapy 
services. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional resin-based composites and upper partial 
denture provided on June 9, 2020, June 16, 2020 and July 2, 2020. 
 
You asked the Plan to pay for the additional resin-based composites and upper partial denture. You say that 
certain medicines caused your teeth to rot and fall out. The Plan denied your request. The Plan says only two 
restorations are covered per calendar year and the upper partial denture is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
two restorations per calendar year. The Plan agreed to pay for two composite restorations which exhausted your 
benefit. The upper partial denture is not a covered benefit. Therefore, we decided that the Plan does not have to 
pay for the additional resin-based composites and upper partial denture provided on June 9, 2020, June 16, 
2020 and July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic rhizotomy (64772). 
 
You asked the Plan to pre-approve an endoscopic rhizotomy. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have 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 an endoscopic rhizotomy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational technique. The service is not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoscopic rhizotomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an endoscopic rhizotomy (64772).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 80157, 80177, 80162, 80159, 80173, and 80201 provided on March 11, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80157, 80177, 80162, 80159, 80173, and 80201 are not supported in the medical record. Specifically, the documentation submitted did not support that these services were performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab results indicate a urine specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 80157, 80177, 80162, 80159, 80173, and 80201 provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on June 1, 2020.You asked the Planto waive the copayment for a specialist office visit. You say that this visit should have been included in your surgery 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 $50 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $50 copayment for a specialist office visit.  The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 a specialist office visit provided by a participating provider on June 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided February 
3, 2020. 
 
You asked the Plan to pay for the ambulance mileage. You say the ambulance service was determined 
necessary by the hospital. You trusted the hospital's arrangement. You do not think it is reasonable to deny the 
payment. The Plan denied your request. The Plan says ambulance mileage beyond the nearest facility is not 
covered under Medicare or the Plan. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. Ambulance 
mileage is only covered to the closest facility. The Plan follows the same rules. The Plan approved the 
ambulance transportation and mileage from the hospital to the nearest skilled nursing facility. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for non-
covered ambulance mileage (A0888) provided February 3, 2020.
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 meets the criteria for coverage. You say 
that the enrollee will benefit from care in an IRF that cannot be accomplished at a lower level. You say that the 
clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says the 
records do not show the enrollee needs an intensive team for care. The Plan says that the enrollee can safely 
receive the services needed in another setting. 
 
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 evidence of medical issues that require monitoring by an inpatient rehab 
physician three times a week. While the enrollee may benefit from physical and occupational therapy, the 
documentation does not support that there is a need for a specialized and intensive therapy program with 3 
hours a day and an interdisciplinary approach to rehab care. The enrollee's rehab needs can be met in an 
alternate, less intense setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this will prevent foot deterioration. The Plan 
denied your request. The Plan says there is no supplemental benefit for this. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided 
on February 17, 2020. 
 
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that your benefits 
show a $0 copayment for routine services with an in-network or out-of-network provider. You say that you are 
not receiving the full amount of reimbursement. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for your covered routine dental services from an out-of-network provider. You are responsible 
for the remaining amount. Therefore, we decided that the Plan does not have to pay more for the prophylaxis 
and periodic oral evaluation provided on February 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the stimulator 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 Spinal Cord Stimulators are covered when 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 spinal cord stimulator. Our reviewer 
says that the spinal stimulator is not medically necessary. Our physician reviewer found the enrollee does not 
have an evidence based indication for a spinal cord stimulator trial. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple self-administered drugs received on May 21 to May 
23, 2020. 
 
You asked the Plan to pay for multiple self-administered drugs. You say that these drugs were administered by 
the nurse on duty and ordered by your doctor. The Plan denied your request. The Plan says rules for payment 
for self-administered drugs have not been met. 
 
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 pay for multiple self-administered drugs 
received on May 21 to May 23, 2020.