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

 
We decided that the Plan does not have to pay for the chiropractic physical therapy services provided on 
October 21, 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered chiropractic services. 
 
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 physical therapy services provided on October 21,
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and treatment (99214) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve an evaluation and treatment 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 this service. 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 
an evaluation and treatment (99214) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 1, 2019 
to November 2, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 1, 2019 to November 2, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on 
September 6, 2019. 
 
You asked the Plan to pay for CTC testing. You say that the Plan must cover Medicare-covered services. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests 
are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that circulating tumor cell (CTC) assays are not 
covered by Medicare for date of service September 6, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CTC testing have not been met. Therefore, we decided that the Plan does not have to pay for 
circulating tumor cell (CTC) assay testing provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heel stabilizers and ankle foot orthoses provided on 
February 22, 2020. 
 
You asked the Plan to pay for the heel stabilizers (L3170) and ankle foot orthoses (L1971). You say that the 
orthoses were medically necessary. The Plan denied your request. The Plan says reasonableness of the orthoses 
is not established. 
 
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 physician order and proof of delivery for the supplies provided in this case. 
The physician order is signed before the date of the telehealth exam. There is no proof of delivery. Therefore, 
we decided that the Plan does not have to pay for the heel stabilizers and ankle foot orthoses provided on 
February 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service your husband called 
for an ambulance for you because he was concerned about the pain you were experiencing. You say that your 
husband's health was declining at the time and he was unable to care for himself. You say that because of your 
husband's needs, you could not leave him alone and you knew that if you were transported, you would be 
admitted to the hospital. You stated that because of his lack of the ability to take care of himself, you refused to 
go to the hospital and you eventually felt better later in the evening. You say that you feel like you made the 
right choice for you and your husband, and you asked the Plan to reconsider providing coverage for the 
services. 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 7, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided requiring admission to a LTACH. The enrollee still requires acute hospital level of 
care services and is receiving appropriate care at the present acute care hospital. At the time the enrollee is 
considered medically stable by her treating team she may be an appropriate candidate for care at a less intense 
level such as a skilled nursing facility. The review has determined that the enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you are not willing to see an in-office provider. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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 provider.
Appeal type: Outpatient Therapies
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 can be provided by a 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 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on March 4, 2020. 
 
You asked the Plan to pay for the transportation services. You say that the transportation to your neurologist 
was medically necessary. 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 wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of a right occipital lobe arterio-venous malformation rupture with seizure disorder who presented to the 
acute hospital on 08/09/2020 with status epileticus. She was treated in the hospital with intravenous 
anticonvulsants and mechanical ventilation for respiratory failure. She has now been extubated. She is weak 
and deconditioned and is non-ambulatory at baseline. She has been evaluated by physical and occupational 
therapy in the hospital. She is total assist for mobility and for transfers and activities of daily living. Notes 
indicate that "she will not cooperate with motor or sensory exam." She is otherwise medically stable and is 
ready for hospital discharge. 
 
 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services. Based on the medical records provided this enrollee does not require skilled therapy services. Based 
on the medical records provided daily skilled services are not required. Based on the medical records provided 
this enrollee does not require the 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic dental x-rays (D0330) and dental extractions 
(D7140) provided May 19, 2020 to May 26, 2020. 
 
You asked the Plan to pay for the x-rays and extractions. You say that the services were medically necessary. 
The Plan denied your request. The Plan says Panoramic x-rays are not covered and the $200 benefit for 
extractions was exhausted at the time the services were provided. 
 
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 requested items or services are not 
among those covered under this benefit. Coverage is not provided for Panoramic X-rays, and the benefit of 
$200 towards fillings or extractions had been expended on May 19, 2020. Therefore, we decided that the Plan 
does not have to pay for panoramic dental x-rays (D0330) and dental extractions (D7140) provided May 19, 
2020 to May 26, 2020 beyond the $200 already paid
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on February 14, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that the doctor is not responsible for 
authorization. The Plan denied your request. The Plan says this service was not authorized. 
 
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 rest home visit (99336) provided on February 
14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on March 13, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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. The Plan says that 
the referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 lab work provided on March 13, 2020 by an out of 
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 8, 2020. 
 
You asked the Plan to pay for ambulance services. You say that you did not call for the ambulance your 
neighbor did. The Plan denied your request. The Plan says the modifier GY is present on the claim which 
carries enrollee responsibility and it does appear that this was a non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. Medicare rules say that providers must report services correctly. Providers must report 
services with the appropriate CPT code.  
 
We looked at the file and Medicare rules. In this case, the provider submitted their claim for payment with a 
GY modifier that indicates that the services provided were non-covered by Medicare. The ambulance provider 
has submitted a claim that cannot be paid based on Medicare billing guidelines. Because the provider is out-of-
network, the plan cannot over-ride the claim. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on March 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning/prophylaxis provided to the enrollee on April 9, 
2019. 
 
You asked the Plan to pay for the services. You say that previous claims from this office have been paid. The 
Plan denied your request. The Plan says the rendering provider has opted out of Medicare Advantage. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
cleaning/prophylaxis provided to the enrollee on April 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder joint replacement surgery (23472) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve shoulder joint replacement surgery 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 this service. 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 
shoulder joint replacement surgery (23472) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright rolling walker (E1399). 
 
You asked the Plan to pre-approve an upright rolling walker. You say that the walker is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met for the upright rolling walker. 
 
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 upright rolling walker. Our reviewer 
says that the walker is not medically necessary. Our physician reviewer found on review of available records, 
the patient does not meet Medicare coverage criteria for an Upright walker. The documentation does not 
support functional deficits, limitations or justification for a walker upright or otherwise. 
 
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 upright rolling walker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an upright rolling walker (E1399).