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

 
We decided that the Plan does not have to pre-approve 20 acupuncture visits to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve 20 acupuncture visits. You say that the enrollee has explored numerous 
strategies without benefit and is in search of novel and conservative options to reduce the pain. The Plan denied 
your request. The Plan says this service is available with in-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 
20 acupuncture visits to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 25, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on April 25, 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 a determination of refractive state (92015) provided on 
December 30, 2021. 
 You asked the Plan to pay for a determination of refractive state (92015). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this service is not covered under your Plan 
benefits. 
 
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 outpatient physician services for the diagnosis and treatment of diseases and injuries 
of the eye, including treatment for age-related macular degeneration. 
 
We looked at the file and the Plan's rules. Original Medicare does not cover routine eye exams (eye refractions) 
for eyeglasses/contacts. The Plan does not cover routine eye exams, eye refractions or eyeglasses/contacts. 
Therefore, we decided that the Plan does not have to pay for a determination of refractive state (92015) 
provided on December 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental for the treatment of back pain. The services are therefore not reasonable or medically 
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 these services have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on November 17, 2021, to 
November 18, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that the outpatient services are not supported in the medical record. Specifically, these services were 
billed on the same date of service as inpatient services. This means these services are not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been 
met. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on 
November 17, 2021, to November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network outpatient surgery 
provided on April 07, 2022. 
 
You asked the Plan to waive the coinsurance for out of network outpatient surgery. You say that you never 
used anyone who was out of network. The Plan denied your request. The Plan says this cost sharing was 
charged 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 50% 
coinsurance for Out of Network Surgery Services. 
 
 
 
 
 
 You have been asked to pay 50% coinsurance for out of network outpatient surgery. This item/service falls 
within the Out of Network Surgery 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 coinsurance 
for out of network outpatient surgery provided on April 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that this should be covered. The Plan denied 
your request. The Plan says prior authorization was not obtained before the service was 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care (99308) provided on April 
27, 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. The Plan denied your request. The Plan says 
admission to LTACH was denied as not meeting criteria, is not medically necessary, and your needs can be met 
at an alternate level of care. Based on the clinical information received, you do not meet the guidelines for 
long-term acute care services. You can safely receive this care in another setting, such as a skilled nursing 
facility. 
 
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 you were admitted to the acute care hospital with perforated diverticulitis, sepsis, 
peritonitis requiring laparotomy, resection reanastomosis, intubation, antibiotics, nasogastric tube placement, 
total parenteral nutrition, and vasopressor drip. Recent notes describe you as having new pulmonary embolism, 
pneumonia, and anemia requiring ongoing antibiotics, heparin drip, high flow oxygen, and closer monitoring.  You appear to be currently unstable and require short-term additional acute care hospital services that can 
safely be administered at the current facility until more stable and appropriate for a lower level of care. You do 
not require services at the LTACH that are not available at the current facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 17, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you did not do lab work at the 
hospital, so the copayment is wrong. The Plan denied your request. The Plan says this cost sharing was charged 
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 $45 
copayment for Lab services at an outpatient hospital facility. 
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for laboratory services. This item/service falls within the Lab 
services at an outpatient hospital facility 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 laboratory services provided on June 17, 2022.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with bradycardia, chronic decubitus ulcer with osteomyelitis, congestive heart failure, 
hypotension, acute renal failure requiring antibiotics, pacemaker removal, and wound debridement. She is now 
performing physical therapy with plans for outpatient treatment. She appears to be more stable and improving 
and should only require short-term additional acute care hospital services that can safely be administered at the 
current facility. She does not require services at the LTACH that are not already available at the current 
facility. The LTACH services are not reasonable or medically 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95806 billed for date of service July 13, 
2021. 
 
You asked the Plan to pay for procedure code 95806. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95806 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95806 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95806 billed for date of service July 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
28, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for Ambulance Services. 
 
 
 
 
 
 
 You have been asked to pay a $250 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 ambulance transport 
provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service May 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special radiation treatment (proton beam radiation) 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they do not know yet whether Proton Beam Therapy offers an advantage (better health 
outcome) over standard therapy for this enrollee. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the need for proton therapy is usually established with quantitative dosimetric information that 
shows a clinically meaningful reduction in radiation dose exposure of normal tissues. This was not provided for 
this case; therefore, the services are not medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the special radiation treatment (proton beam radiation) to be provided by an out-of-
network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion-single level. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has significant pain and is 
desperate for a surgical solution. The Plan denied your request. The Plan says the records do not show that the 
enrollee meets the criteria 
 
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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MRI does not show spinal stenosis or spinal instability. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion-single level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry visit provided on June 07, 
2022. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that the receptionist told you there 
was no copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for podiatry services. 
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for the podiatry visit. This item/service falls within the podiatry 
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 podiatry visit provided 
on June 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and associated accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and associated accessories. You say that this 
power wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
criteria for coverage of a group 3 power wheelchair have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and associated accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nebulizer with compressor (E0570) provided on April 20, 
2022, to May 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the enrollee received the 
nebulizer and supplies while visiting urgent care. You say the items are medically necessary. The Plan denied 
your request. The Plan says care from out-of-network providers is only covered in cases of emergencies, urgent 
care, and pre-approved care. The Plan says that the rendering provider is not in-network, and the services were 
neither urgent nor emergent. Furthermore, there is no documentation on file to obtain a prior authorization.  
 
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 nebulizer with compressor (E0570) provided on 
April 20, 2022, to May 20, 2022, by an out-of-network (OON) provider.