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

 
We decided that the Plan does not have to pre-approve four additional physical therapy visits (97110). 
 
You asked the Plan to pre-approve four additional physical therapy visits. You say that you require additional 
in office physical therapy sessions to increase your independence and activities of daily living. The Plan denied 
your request. The Plan says it appears that no skilled therapy services are required. 
 
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 four additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that based on the medical records provided, there 
is no documentation that the requested therapy is generally accepted as specific and effective therapy for your 
condition. There is no documentation that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist or 
under the supervision of a therapist. Additionally, you do not need the skill, knowledge and judgment of a 
qualified therapist is required to establish, design and/or deliver a program to maintain your current condition 
or to prevent or slow further deterioration. Based on the available records you appear to have plateaued with 
therapy. Further improvement in your functional status does not appear to be predictable in a reasonable time 
frame to necessitate further skilled therapy services. Further utilization of the home exercise program appears 
appropriate at this point. Repetitive exercise does not require the expertise of a professional skilled physical 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve four additional physical therapy visits (97110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimens to 
you to process, and you would like the claim paid. The Plan denied your request. The Plan says the rendering 
and referring providers are both OON providers and there was no 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 laboratory services provided on April 26, 
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 physical or manipulative therapy performed for maintenance 
provided from February 23, 2022, to March 9, 2022. 
 
You asked the Plan to pay for maintenance therapy. You say that you would like to be reimbursed for these 
services. The Plan denied your request. The Plan says physical or manipulative therapy performed for 
maintenance rather than restoration, is not covered by Medicare or the plan. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical or manipulative therapy performed for maintenance provided from 
February 23, 2022, to March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99204) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you do not like the in-network cardiologist and 
your primary care physician is highly recommending this doctor since they will be working together to get you 
off of some medications. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the outpatient office visit (99204) 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 a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that a basic compression pump is 
not adequate, and the enrollee had a trial of a basic pump but experienced pain and had no reduction in 
swelling. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because the record does not show that the enrollee failed a reasonable trial of a basic pump prior to requesting 
the advanced pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 28, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you would like to request reconsideration of the denied 
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 injections provided on March 28, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria 
for LTACH admission. The Plan denied your request. The Plan says the enrollee does not require extensive or 
complex wound care management by skilled nursing of at least 6.5 hours per day. The enrollee's medical needs 
are being met in the current acute setting. The LTACH would add no additional services. With additional time 
in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be 
determined. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage 
have not been met because the requested service is experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
the safety and effectiveness of the procedure. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
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 you have been waiting for 9 months for 
replacement orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not have a choice 
in the matter of how you got to the hospital that day, therefore, you should not have to pay this copayment. The 
Plan denied your request. The Plan says you were charged this cost sharing 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 $305 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $305 for these 
services. 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 ambulance services provided on February 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied 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 an office visit 
provided on February 28, 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 on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The Plan 
also says there is no referring provider involved in these services. The Plan also says that they did not authorize 
any services for the rendering 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 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 on March 11, 2022, 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 an in-network specialist visit provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that there should not be 
a copayment for this visit. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $30 
copayment for Medicare-covered physician, specialist service.  
 
You have been asked to pay a $30 copayment for an in-network specialist visit. An in-network specialist visit 
falls within the Medicare-Covered Physician, Specialist Service 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 an in-network specialist visit provided on April 14, 2022.
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 needs to be transferred to a rehabilitation 
facility to get to a level to to home. The Plan denied your request. The Plan says the requested admission is not 
medically necessary. 
 
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 provided documentation does not indicate that the enrollee has complex 
nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and waive the coinsurance for physical therapy services 
provided on October 12, 2021 and October 20, 2021. 
 
You asked the Plan to pay for and waive the coinsurance for physical therapy. You say that you were told that 
there would be no further copayments and you are on a fixed income. The Plan denied your request. The Plan 
says the denial of payment for October 12, 2021 is correct because the Plan already paid for these services 
under a separate claim. The Plan also says that the coinsurance amount you are being charged is correct. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 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 40% 
coinsurance for out-of-network physical therapy. The allowed amount of the services on October 20, 2021 is 
$94.81, resulting in a coinsurance amount of $37.93. 
 
We looked at the file and Medicare rules. The file includes evidence that physical therapy services on October 
12, 2021 were reimbursed by the Plan on October 25, 2021. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. You have also been asked to pay 40% coinsurance for physical therapy. Physical therapy 
falls within the Outpatient Rehabilitation 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 pay for and 
waive the coinsurance for physical therapy services provided on October 12, 2021 and October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) received on January 24, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you want the Plan to reimburse you for the hearing 
aids. The Plan denied your request. The Plan says the items were received from a non-participating provider 
and are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the Plan's vendor network is utilized.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network 
vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298) 
received on January 24, 2022.