Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for high frequency chest wall oscillation system provided on 
February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for high frequency chest wall oscillation system. You say that you want this denied 
as patient's responsibility so you can bill the secondary insurance. The Plan denied your request. The Plan says 
the reason for denial is this is an out-of-network vendor. 
 
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 had network providers 
available who could have provided 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 high frequency chest wall oscillation system 
provided on February 23, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3310) and personal protective equipment 
(PPE) (D1999) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a sales agent that the root 
canal would be covered. You also say that this should be covered. The Plan denied your request. The Plan says 
root canal, an endodontic service, is not listed as 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the root canal is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) 
and personal protective equipment (PPE) (D1999) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on August 17, 2021. 
 
You asked the Plan to pay for dentures. You say that you were under the impression that the claim could still 
be paid at a reduced rate when seeing an out-of-network provider. You also say the provider availability was 
limited due to the pandemic. The Plan denied your request. The Plan says the services are not covered when 
seen by an out-of-network provider. 
 
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 record shows you received dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received by an out-of-network provider. Therefore, we decided that the Plan does not have to pay 
for complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on August 17, 2021.
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 you feel you need this level of rehabilitation in order 
to return home. The Plan denied your request. The Plan says the documentation provided does not indicate that 
you meet the criteria for the level of care requested. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 the request for acute inpatient rehabilitation was considered not medically 
necessary per guideline policy with the rationale that you do not have the medical complexity requiring 
specialized rehabilitation. Our physician reviewer found there are no complex nursing or rehabilitation needs. 
While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the records provided support the need for the 
requested injection services. The Plan denied your request. The Plan says there has not been prior adverse 
events or failure of at least two of the preferred medications. The Plan says that the enrollee has not been given 
the non-preferred Monovisc within the last 365 days. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monovisc. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Orthovisc, Synvisc, or Synvisc before they will approve the requested drug. There is no evidence that the 
enrollee has had a trial of one of the preferred agents. There is no documentation showing that the Plan's 
required drugs would likely be less effective and/or likely have an adverse effect for 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (99306) provided on December 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network nursing care. You say that these services were rendered in good 
faith as they were medically necessary. The Plan denied your request. The Plan says out-of-network care is 
covered only in certain limited circumstances. The service at issue was not urgent or emergent, nor was it pre-
approved. 
 
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 had network providers 
available who could have provided 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 initial nursing facility care (99306) provided on 
December 29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (placement of a peripheral nerve 
stimulator over the suprascapular nerve). 
 
You asked the Plan to pre-approve placement of a peripheral nerve stimulator over the suprascapular nerve.. 
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 placement of a peripheral nerve 
stimulator over the suprascapular nerve. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found you have had right shoulder 
pain for two years. You have tried non-steroidal anti-inflammatory drugs, muscle relaxants, and opioids. You 
have had physical therapy, chiropractic and steroid injections. The requested services are considered an 
experimental/investigational procedure. Therefore, you do 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 placement of a peripheral nerve stimulator over the suprascapular nerve. have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of 
peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling (placement of a 
peripheral nerve stimulator over the suprascapular nerve).
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 this provider and the patient strongly 
disagree with the medical director who denied this original request and feel the patient meets criteria for 
LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, the Long-Term Acute 
Care Hospital (LTACH) services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan, and they have approved ongoing care in the 
current acute care setting. Our physician reviewer also found that the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on January 23, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compression device. You say that please deny as patients 
responsibility so we can bill secondary insurance. 
 The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-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 had network providers 
available who could have provided 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 a pneumatic compression device provided on 
January 23, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) trial and implantable 
electrode. 
 
You asked the Plan to pre-approve spinal cord stimulator (SCS) trial and implantable electrode. 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 follows Medicare rules. Medicare rules say that SCS trials are only covered for certain indications. 
 
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 spinal cord stimulator (SCS) trial and 
implantable electrode. Our reviewer says that the documentation does not support that the Our physician 
reviewer found the enrollee has low back pain. The enrollee reported only mild levels of back pain and 
funstional impairment in the SCS evaluation report. Not enough disability and pain have been reported to make 
the stimulator device medically needed at this time. 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 spinal cord stimulator (SCS) trial and implantable electrode have not been met. 
Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) trial and 
implantable electrode.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedures on the nails provided on February 28, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical procedures on the nails. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 surgical procedures on the nails provided on 
February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on December 31, 2021. 
 
You asked the Plan to pay for CT of the head or brain. You say that this claim was denied in error and should 
be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on October 
15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 had network providers 
available who could have provided 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 drug testing services (80307, G0483) provided on 
October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional duplex scan provided to the enrollee on July 
29, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an exact duplicate of a charge previously considered and identified. 
 
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 93880 is "Duplex scan of extracranial arteries; complete 
bilateral study." 
 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records show one unit of 
bilateral duplex extracranial arterial - CPT 93880 - to have been done on 7/29/20, signed by the radiologist. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional duplex scan provided to the enrollee on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on March 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you have provided the medical record to 
support medical necessity and would like payment for the claim. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 clinic visit provided on March 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by an OON provider on January 21, 
2022. 
 
You asked the Plan to pay for an office visit. You say that this enrollee has never had to have an authorization 
for an office visit to see one of our providers. The Plan denied your request. The Plan says the out-of-network 
services were 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 OON 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 had network providers 
available who could have provided 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 an office visit provided by an OON provider on 
January 21, 2022.