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

 
We decided that the Plan does not have to waive the copayment for injections into spine using imaging 
guidance provided on January 26, 2022, and February 10, 2022. 
 
You asked the Plan to waive the copayment for injections into spine. You say that you don't understand why 
these services were not paid in full. The Plan denied your request. The Plan says the copayments applied are 
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 $400 
copayment for Medicare-covered surgery or other services provided to you at a Tier 2 ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 You have been asked to pay $344.58 per service for a total of $689.16 which is less than the standard $400 
copayment for injections into spine. Injections into spine falls within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 injections into spine using imaging guidance provided on 
January 26, 2022, and February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that whoever is on duty at the time of service 
reads the radiologist diagnostic tests. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on December 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 23, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that the services were rendered to the enrollee 
out of medical necessity, and you would like the claim processed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. 
 
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 wound care services provided on September 
23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (intranasal radiofrequency 
ablation) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the VivAer procedure in the 
setting of nasal congestion have not been demonstrated in the peer-reviewed literature. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is insufficient 
evidence that the VivAer procedure is safe and effective and is at least as effective as existing and available 
medically appropriate alternatives. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the VivAer procedure (intranasal 
radiofrequency ablation) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee from January 
14, 2022 and February 2, 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 it is unlikely that immediate medical treatment of an emergent illness or injury could have been 
provided at the reported destination. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The documentation 
did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for this member. The documentation did not support that the enrollee 
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on. The documentation did not support that the ambulance transport 
was medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee from January 14, 2022 and February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac resynchronization therapy (CRT) pacemaker. 
 
You asked the Plan to pre-approve cardiac resynchronization therapy (CRT) pacemaker. You say that cardiac 
resynchronization therapy (CRT) pacemaker is medically necessary. The Plan denied your request. The Plan 
says the cardiac resynchronization therapy (CRT) pacemaker does not meet the MCG 26th edition: Cardiac 
Pacemaker Implantation or Replacement ACG: A-0167 coverage 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 cardiac resynchronization therapy 
(CRT) pacemaker. Our reviewer says that the cardiac resynchronization therapy (CRT) pacemaker is not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation of a repeat echocardiogram after administration of optimal medical therapy, as guidelines 
suggest. Moreover, the degree of left ventricular dysfunction is not severe at 47%, well above the 35% 
threshold cited by guidelines for CRT-P candidacy and likelihood of favorable response to bi-ventricular 
pacing. In summary, there is insufficient documentation to support the medical necessity for removal of the 
single-chamber pacemaker and replacement with a bi-ventricular pacemaker.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac resynchronization therapy (CRT) pacemaker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cardiac resynchronization therapy (CRT) 
pacemaker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81455) provided on November 
16, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says genetic testing procedures submitted 
with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services (81455) provided on November 16, 2021, have been met. In this case, no medical records were received from the 
enrollees ordering provider. This documentation is required to establish the medical necessity of the requested 
testing. Therefore, we decided that the Plan does not have to pay for the genetic testing services (81455) 
provided on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided to the 
enrollee on December 9, 2021. 
 
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 one hospital discharge is allowed per stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
It is only appropriate to bill CPT 99239 once in a day. 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 hospital discharge day management services provided to the enrollee on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the longer the enrollee remains in hospital he 
declines in his abilities to walk or preform daily living and inquire other hospital diseases such as covid as well 
as the enrollee came in with septic shock. The Plan denied your request. The Plan says the records do not show 
that the enrollee needs to be seen by a rehab doctor at least 3 times a week for evaluation of functional and 
medical goals and progress or that they need an intensive team for their care. The enrollee can safely receive 
the services they need in other settings, for example: a skilled nursing facility, home with home health services 
or home with outpatient therapy. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation (PM&R) physician's supervision 3 times per week (at a minimum) for the ongoing management 
of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs identified or 
documented. 
 
At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not 
medically necessary based on lack of medical complexity and acute rehab nursing needs and high functional 
level. Document does not support the medical necessity for admission to an IRF. 
 
While the enrollee may benefit from continued PT and OT, his rehab needs can be safely provided in a lower 
intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (ER) on January 
07, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you are not able to 
afford this ER visit copay because you have no money. The Plan denied your request. The Plan says the cost-
sharing you are being charged is 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 $75 
copay per emergency care stay for Specified Low-Income Medicare Beneficiary (SLMB) members. Emergency 
care refers to services that are: Furnished by a provider qualified to furnish emergency services and needed to 
evaluate or stabilize an emergency medical condition. 
 
 
 
 You have been asked to pay a $75 copayment for emergency room services. Emergency room services 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 (ER) on January 07, 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 more aggressive rehabilitation 
than what a skilled nursing facility can offer. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval. 
 
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 was admitted to an acute hospital after a fall. The enrollee is 
medically stable, and comorbid conditions are stable. There are no complex nursing or rehabilitation needs. 
While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. The enrollees care needs can be safely provided in a lower intensity and 
alternate setting such as in a skilled nursing 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 29, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
per the medical records. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medial branch block at L3-L4 and L4-L5 (CPT 
64493, 64494, 64495). 
 
You asked the Plan to pre-approve the injection services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the records do not support that this 
service is needed to treat the enrollee's condition and does not support the coverage 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 injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has leg pain. He takes Ibuprofen, Gabapentin and Tylenol. He had an SI 
joint injection which relieved 90% of his pain. His MRI shows multi-level spinal stenosis, multi-level disc 
bulges, and multi-level foraminal stenosis as well as facet arthropathy. The enrollee has multiple pain 
generators and therefore, does not meet the criteria of the LCD. The requested procedure 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 the injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the medial branch block at L3-L4 and L4-L5 (CPT 64493, 64494, 64495).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan for the enrollee. 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee needs the CT to have his cancer 
checked. The Plan denied your request. The Plan says that that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that a CT 
scan is medically reasonable and necessary. The enrollee has right lung carcinoma, status post stereotactic 
radition. Chest CTs are allowed every 6 months for up to 3 years. Our physician reviewer found that the 
enrollee's condition meets criteria for coverage of a CT scan. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan for the enrollee.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for mental health services provided from 
August 5, 2021, to March 1, 2022. 
 
You asked the Plan to reduce the copayments for the mental health services. You say that you were informed 
your copayments were only $5. 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 $40 
copayment for each therapy visit.  
 
You have been asked to pay a $40 copayment for each of the 29 visits for the mental health services. The total for all services is $1,160 ($40 copayment x 29 visits = $1,160). The mental health 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 reduce the copayments for 
mental health services provided from August 5, 2021, to March 1, 2022.  
 
Your complaint about misinformation regarding copayments from the provider and the Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.