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

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 28, 
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 February 28, 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 
February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat right-sided medial branch block (MBB). 
 
You asked the Plan to pre-approve the repeat MBB. You say that the enrollee has positive response to the first 
MBB getting her pain down to a 3/10. The Plan denied your request. The Plan says reduction in pain from 7/10 
to 3/10 is not sufficient to indicate a positive response. 
 
The Plan follows Medicare rules. Medicare rules say that repeat MBBs are covered when the initial MBB 
produces at least 80% pain relief. 
 
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 repeat MBB. Our reviewer says that 
the requested repeat MBB is not considered reasonable and necessary. Our physician reviewer found the 
enrollee is a female with low back pain and lumbosacral spondylosis without myelopathy. The prescriber states 
the enrollee had 2 injections within the past 12 months (Left L3-S1 Lumbar Rhizotomy on 11/13/2019 and 
Right L3-S1 MBB on 6/23/2020). The patient's VAS score from the first right L3-S1 MBB on 6/23/2020 
dropped from 7/10 to 3/10. The prescriber is requesting a repeat MBB. The enrollee's medical history is 
significant for lumbar spondylosis, acquired postural kyphosis, inflammation of sacroiliac joint, spondylosis 
without myelopathy, lumbosacral stenosis, and lumbosacral radiculopathy. Medical records were provided. The 
provided medical records do not document that the enrollee has satisfied the coverage criteria.  Therefore, the 
requested injections are not 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 repeat MBB have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat right-sided medial branch block (MBB).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPECT (78452). 
 
You asked the Plan to pre-approve SPECT. You say that you would like reconsideration because this service is 
necessary for the member's employment. The Plan denied your request. The Plan says such tests used for 
screening that are not anticipated to influence medical management shall be denied for lacking medical 
necessity. 
 
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 SPECT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member has no symptoms and no ischemia on prior nuclear stress testing about 1 year ago.  
In this circumstance of a stable member with a recent nuclear stress test a repeat nuclear stress test < 2 years 
from the prior exam is not supported by the medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SPECT (78452).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell down and needed help to get back 
up. 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 April 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 28, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion 
catheter (A4221) infusion supplies for external drug infusion pump (A4222) Epoprostenol injection (J1325) 
infusion pump used for uninterrupted parenteral administration of medication provided September 23, 2019 to 
October 22, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that appropriate clinical documentation was 
provided and you request reversal of the decision to deny. Services were provided in good faith and in 
accordance to the written prescription. The Plan denied your request. The Plan says the records do not support 
the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter 
(A4221) infusion supplies for external drug infusion pump (A4222) Epoprostenol injection (J1325) infusion 
pump used for uninterrupted parenteral administration of medication provided September 23, 2019 to October 
22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from May 30, 2018 to 
November 27, 2018 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you feel that these services should be paid by the 
Plan. The Plan denied your request. The Plan says these services were not provided by a network provider. 
There are network providers able to provide this care and no prior authorization to see an OON provider was 
received. 
 
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 from May 30, 2018 
to November 27, 2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
had on April 20, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you thought that under this Plan the only 
cost sharing applicable would be if you were hospitalized. You say that you cannot afford this copayment. The 
Plan denied your request. The Plan says you were charged this copayment correctly. 
 
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 $95 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $95 copayment for the MRI. The MRI falls within the diagnostic and nuclear 
medicine 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 the 
magnetic resonance imaging (MRI) you had on April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient stay. 
 
You asked the Plan to pre-approve an inpatient stay. 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 an inpatient stay. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the care provided to you was observation level. There were no advance interventions or 
complex medical conditions. You had stable vital signs and no complaints at the time of admission. Inpatient 
services were not supported by the documentation. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient stay.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you are able to get the necessary rehabilitation, such as physical 
therapy and occupational therapy at the skilled nursing level of care with the goal of safely returning home. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
care. 
 
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 proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the radiation oncologist did not provide a comparative plan. Without this 
information, the rationale for the need for proton therapy is not well-justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an aqueous drainage device(s) (stents or 
shunts). 
 
You asked the Plan to pre-approve insertion of an aqueous drainage device(s). You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed the 
benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that more than one aqueous drainage devices (or 
shunts) for the correction of increased pressure in the eye are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of insertion of an aqueous drainage device(s) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of an aqueous drainage device(s) (stents or shunts).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on April 1, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 established patient office or other outpatient 
visit (99214) provided on April 1, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (97161). 
 
You asked the Plan to pre-approve physical therapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee can manage her symptoms with a home program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had therapy for this condition and it does not appear 
that she requires the unique skills of a professional therapist to safely and effectively provide treatment, or that 
the services can be safely and effectively performed only by or under the supervision of a therapist. The 
enrollee should be able to transition to an independent exercise program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued physical therapy (97161).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 24, 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 March 24, 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 March 
24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
June 23, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $45 copayment for the specialist office visit provided. 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 the office visit (99213) provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions for teeth 6-13 and 20-30. 
 
You asked the Plan to pre-approve dental extractions. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services exceeds your benefit limit. 
 
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 dental 
extractions when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Review of the file shows that you had extractions done on teeth 3 and 
4 on September 10, 2020. Your coverage with the plan only covers two dental extractions per calendar year. 
Based on this information, we decided that the Plan's rules for coverage of dental extractions have not been 
met. Therefore, we decided that the Plan does not have to pre-approve dental extractions for teeth 6-13 and 20-
30.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425 and A0429) provided on 
November 20, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says modifiers identifying the place of origin 
and destination of the ambulance trip must be submitted on all ambulance claims. 
 
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 A0425 and A0429 are not supported in the record. Specifically, the submitted claim 
was not billed with the necessary modifiers to indicate origin and destination. Based on this information, we 
decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for ambulance services (A0425 and A0429) provided on November 20, 
2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture (97813 and 97814) and manual therapy (97140) provided 
on October 8, 2019 through December 11, 2019. 
 
You asked the Plan to pay for the acupuncture and manual therapy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 97813 is acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-
on-one contact with the patient. 
 
The CPT Code Manual definition of code 97814 is acupuncture, 1 or more needles; with electrical stimulation, 
each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List 
separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of 97140 is manual therapy techniques (eg, mobilization/ manipulation, 
manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. 
 
We asked our coder 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 acupuncture and manual therapy. Our reviewers says that 
CPT codes 97813, 97814 and 97140 meet criteria for billing and reimbursement consideration. Our reviewer 
found the patient record documents Chief Complaint, Exam and Treatment.  CPT 97813, CPT 97140 and CPT 
97140 are documented under treatment for all dates of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acupuncture and manual therapy have been met. Therefore, we decided that 
the Plan has to pay for acupuncture (97813 and 97814) and manual therapy (97140) provided on October 8, 
2019 through December 11, 2019.  
 
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.