Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radical resection of a tumor, soft tissue of pelvis and 
hip area (27059). 
 
You asked the Plan to pre-approve a radical resection of a tumor. You say that the enrollee has a diagnosis of 
prostate cancer and has been waiting over 3 months for surgery. The denial for this procedure is delaying your 
fathers care and causing excruciating pain. The Plan denied your request. The Plan says the three major codes 
have been approved for surgery by the Plan. The enrollee's doctors office requested a code to remove a benign 
mass that may or may not need to be removed when it is examined at the time of surgery. The provider can 
perform the requested procedure using these codes to start. If they must do more than the codes that are 
approved, they can bill with the operative report for review. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 27059 is not supported in the medical record. Specifically, the main code for surgery is 
approved by the Plan. It is not clear if CPT 27059 is allowed to be billed with the other codes or that it will 
require additional services. It can be billed after the surgery post service. Based on this information, we decided 
that Medicare rules for coverage of a radical resection of a tumor have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a radical resection of a tumor, soft tissue of 
pelvis and hip area (27059).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 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 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 an office visit provided on February 16, 2022 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on March 1, 2022. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item.  
 
 
  The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. 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 a lumbar-sacral orthosis (L0650) provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (72110) provided on December 2, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 x-ray (72110) provided on December 2, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air-fluidized bed/mattress/sand mattress 
 
You asked the Plan to pre-approve an air-fluidized bed/mattress/sand mattress. You say that the medical 
records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria under Medicare or the Plan. 
 
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 air-fluidized bed/mattress/sand 
mattress. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a stage IV sacrococcygeal pressure sore. 
He has been receiving structured wound care and was recently hospitalized for infection and anemia likely 
secondary to the pressure sore. The enrollee was discharged home with a wound VAC and follow for wound 
care. His current bed and air mattress are non-functional and in disrepair. The enrollee requires an air fluidized 
bed from a medical perspective but per guideline criteria there is inadequate documentation indicating that the 
enrollees home is sufficient to support the air fluidized bed. Additionally, there is inadequate documentation if 
the enrollees caregivers can adequately operate the air fluid is bed. Therefore, the requested air fluidized bed is 
considered not medically necessary per guideline criteria until there can be clarification regarding the patients 
home and caregiver support for the use of the requested bed. 
 
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 air-fluidized bed/mattress/sand mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an air-fluidized bed/mattress/sand mattress
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall within the 
Outpatient Mental Health Care 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 
out-of-network (OON) psychotherapy services provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with power tilt. 
 
You asked the Plan to pre-approve a power wheelchair. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says that the enrollee does not have a medical need for a group 3 power 
wheelchair with the requested power options. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 a power wheelchair. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation and plan documentation both state that enrollee is unable to 
complete pressure relief independently and has impaired sensation thus would meet criteria for power tilt. The 
enrollee has a diagnosis of stroke with hemiplegia, is wheelchair bound and is unable to self-propel. Therefore, 
the enrollee would meet criteria for the requested group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have been met. Therefore, we decided that the Plan has to 
pre-approve a group 3 power wheelchair with power tilt.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory virus nucleic acid testing (87631) provided on 
March 1, 2022. 
 
You asked the Plan to pay for respiratory virus nucleic acid testing. You say that the criteria for coverage of 
this service have been met. The Plan denied your request. The Plan says this was not ordered by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician.  
 
We looked at the file and Medicare rules. The Plan has confirmed with the ordering provider that the testing at 
issue was not ordered. Based on this information, we decided that Medicare rules for coverage of respiratory 
virus nucleic acid testing have not been met. Therefore, we decided that the Plan does not have to pay for 
respiratory virus nucleic acid testing (87631) provided on March 1, 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 records provided support the need or IRF care. 
You say that the enrollee is able to tolerate 3 hours of therapy per day in rehabilitation and a treatment in a 
lesser intensity and specialty service could lead to an unfavorable outcome. The Plan denied your request. The 
Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can 
be met at a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sternal fracture, rib fracture, and clavicle fracture after a fall. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the new lenses for old frames (S0595) provided on January 25, 2022. 
 
You asked the Plan to pay for the new lenses for old frames. You say that the technician explained that you 
only had to have the lens made, because the medical plan did not cover almost anything for the frame. The Plan 
denied your request. The Plan says that dispensing new lenses for supplied frames is not a covered benefit. The 
Plan also says that the provider gave you an insurance assignment policy and agreement, signed by you, where 
you understood this service was not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers frames, lenses, and a fitting. 
 
We looked at the file and the Plan's rules. The contract states that both eyeglass options you can choose from 
include frames and lenses. The Evidence of Coverage does not clearly state that you must get both frames and 
lenses together, and that purchasing either frames or lenses alone would not be covered. Based on this 
information, we decided that the Plan's rules for coverage of the new lenses for old frames have been met. 
Therefore, we decided that the Plan has to pay for the new lenses for old frames (S0595) provided on January 
25, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for ER visit provided on February 18, 2022. 
 
You asked the Plan to waive the deductible for ER visit. You say that you should only have to pay $75 
copayment. The Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible which applies to Emergency Services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Emergency 
Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to Emergency Services. This cost sharing is a contractual obligation that had not been 
met at the time ER visit was received on February 18, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for ER visit provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stress test provided on January 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a stress test. 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 a stress test provided on January 25, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that without LTACH care the enrollee is very 
high risk for recidivism and suffering further complications related to the deterioration of his current clinical 
status resulting from his complex comorbidities. The Plan denied your request. The Plan says the guidelines for 
coverage of LTACH care haven not been met. The Plan says that the enrollee can safely receive the care 
needed in the current hospital setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. 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 health plan has approved ongoing care in the 
current acute care setting. 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.