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

 
We decided that the Plan does not have to pay for the wound care supplies provided on October 11, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee was in a nursing home and 
authorization should not be required. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins (D2950) provided on 
September 8, 2022. 
 
You asked the Plan to pay for dental services. You say that the billed service should be covered by your 
insurance. You say you were not told it would not be covered. The Plan denied your request. The Plan says this 
service is not covered under your Plan. 
 
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. Core buildup, including any 
pins (D2950) is not covered under the Plans dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins (D2950) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous lumbar intravertebral disc injection 
procedure. 
 
You asked the Plan to pre-approve a percutaneous lumbar intravertebral disc injection (VIA Disc) procedure. 
You say that a percutaneous lumbar intravertebral disc injection procedure is medically necessary. The Plan 
denied your request. The Plan says the requested percutaneous lumbar intravertebral disc injection procedure is 
experimental and 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 a percutaneous lumbar intravertebral 
disc injection procedure. Our reviewer says that the requested percutaneous lumbar intravertebral disc injection 
procedure is not considered medically reasonable and necessary. Our physician reviewer found that the 
provider is requesting the injection of VIA Disc into the spinal disc for advanced degenerative disc disease 
against the Food and Drug Administration (FDA) approval guidelines. Large well-designed studies in the peer 
review scientific literature comparing stand-alone use of VIA Disc to established treatments are 
needed.  Published studies do not demonstrate any long-term health outcome advantage with the use of VIA Disc as an alternative to standard treatments. 
 
The review has determined that the services at issue in this case are 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 percutaneous lumbar intravertebral disc injection procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a percutaneous lumbar intravertebral disc 
injection (VIA Disc) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health service provided on August 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient mental health service. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no prior authorization or referral on file 
for the services 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 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 outpatient mental health service provided on 
August 1, 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate 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 that you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services at a 
lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder procedure provided on February 
16, 2022, and June 6, 2022. 
 
You asked the Plan to waive the copayment for a bladder procedure. You say that this amount is too high, it 
needs to be changed. 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 $295 
copayment for outpatient hospital services, and a $30 copayment for Physician/Practitioner services, including 
doctors office visits. You have been charged $274.66 rather than the $295 copayment ($274.66 + $30 = 
$304.66).  
 
You have been asked to pay a $304.66 copayment for a bladder procedure. This item/service falls within the 
outpatient hospital services, and Physician/Practitioner services, including doctors office visits 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 a bladder procedure provided on 
February 16, 2022, and June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided to the enrollee on July 13, 
2022. 
 
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 there is no face-to-face encounter, evaluation and management note, or progress note, to support 
this orthosis. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the member has had a new injury or surgery that 
would necessitate a spinal orthosis.  There is no documentation to support that the member was having 
significant pain that would require restricting mobility of the trunk or that the member has weak or deformed 
spine or spinal muscles. The requested spinal orthosis is 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 pay for a lumbar-sacral orthosis provided to the enrollee on July 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health podiatry visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says an outpatient visit can be arranged as the enrollee is able to move around. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that in this 
case, the documentation doesnt support that the enrollee requires a home visit from a podiatry practitioner to 
provide treatment that is medically necessary. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The enrollee can have outpatient podiatry 
services as needed. The requested home health 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health podiatry visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on May 20, 2022. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says per the 
benefits outlined in the Evidence of Coverage; the member was entitled to one annual wellness visit per 
calendar year. The Plans research demonstrates that the member previously had an annual wellness visit on 
January 27, 2022 with an in-network provider. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on 
May 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
18, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical assessment 
provided on July 8, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical assessment. The Plan denied 
your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a psychiatric diagnostic evaluation with medical assessment 
provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve below knee flexible protective outer surface covering 
system (CPT code L5962). 
 
You asked the Plan to pre-approve the item. You say that the enrollee needs this covering. The Plan denied 
your request. The Plan says the records do not indicate that the enrollee is exposed to harsh conditions that 
require extra protection. 
 
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 item. Our physician reviewer found 
the enrollee does not live or work in a harsh environment. There is no medical necessity for the added outer 
protection per A52496. 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 item have not been met. Therefore, we decided 
that the Plan does not have to pre-approve below knee flexible protective outer surface covering system (CPT 
code L5962).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac catheterization (CPT code 93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee has a normal stress test with symptoms of dyspnea, The Plan 
states a left catheterization is not medically necessary at this time. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a stress test performed in 2022 was negative for ischemia. The documentation does not support 
the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary in this enrollee's clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the cardiac catheterization (CPT code 93458).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 88291 for August 4, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 pay for the laboratory services 
billed with code 88291 for August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions, surgical drainage of an abscess, limited oral 
exam, and x-rays (D7210, D7511, D0220, D0140) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 dental benefit maximum allowance 
for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 06/29/2022. Therefore, 
we decided that the Plan does not have to pay for extractions, surgical drainage of an abscess, limited oral 
exam, and x-rays (D7210, D7511, D0220, D0140) provided on June 22, 2022.
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 enrollee requires physician oversight for their 
medical needs as well as extensive physical and occupational therapies to address their significant decline in 
their functional status. You say that the enrollee requires a higher level of rehab services to optimize their 
mobility and strength for their return home. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met at an alternate 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 that the enrollee is deconditioned and does not require intensive rehabilitation. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapies provided on June 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient therapies. You say that the reports attached support the services 
provided. The Plan denied your request. The Plan says there is no referral or prior authorization on file for the 
services 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 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 outpatient therapies 
provided on June 30, 2021, by an out-of-network (OON) provider.