Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on August 30, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport service was not medically necessary. 
Our physician reviewer found the enrollee was transported from the emergency department to the long term 
care facility via stretcher.  
 The record does not indicate that the enrollee's  clinical condition is such that other methods of transport, such 
as a stretcher, were contraindicated or that the expertise, services and lifesaving and life-sustaining equipment 
that only a fully equipped ambulance can provide was required. The record also does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on August 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos. 
 
You asked the Plan to pre-approve Tymlos. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tymlos.  
 
Benefits for Tymlos may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on July 7, 2022, and July 13, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the claims were resubmitted because they 
were previously processed as chiropractic not physical therapy. The Plan denied your request. The Plan says 
that this service is not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan's denial reason is not supported by the case file and they 
did not provide us with any other evidence to support their denial. Therefore, we decided that the Plan has to 
pay for physical therapy services provided on July 7, 2022, and July 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation visits 
provided on September 3, 2020, and September 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital observation visits. You say that you say that 
you receive the service per your provider's request. 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 $100 
copayment for each outpatient observation visit.  
 
  You have been asked to pay $189.13, for outpatient hospital observation visits.  
 
Date of Service Service Standard Cost Member Liability 
September 3, 2020 Observation visits $100 $100 
September 24, 2020 Observation visits $100 $89.13 
TOTAL:   $189.13 
 
The outpatient hospital observation visits fall within the Outpatient hospital observation 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 outpatient hospital observation visits provided on September 
3, 2020, and September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (GCM) unit provided on April 
12, 2022. 
 
You asked the Plan to pay for a CGM. You say that this CGM is medically necessary. The Plan denied your 
request. The Plan says a valid proof of delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. A valid delivery confirmation was not provided. 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 continuous glucose monitor (GCM) unit 
provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (cpap) device 
(E0601), a humidifier, heated (E0562), a full-face mask (A7030), a filter, non-disposable (A7039) and tubing 
with integrated heating element (A4604). 
 
You asked the Plan to pre-approve a CPAP device and accessories. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the records we received do not satisfy the Medicare guidelines. 
Your notes did not support the need for this service. There were no notes showing a sleep study or sleep test 
with specific information. Your condition can be managed by observation. 
 
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 CPAP device and accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a listed diagnosis of sleep apnea, but the records do not provide 
the results of a sleep study to confirm the diagnosis. There is no complete sleep history, assessment of daytime 
sleepiness, neck circumference, or detailed upper airway examination. 
 
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 CPAP device and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous positive airway pressure (cpap) device (E0601), a 
humidifier, heated (E0562), a full-face mask (A7030), a filter, non-disposable (A7039) and tubing with 
integrated heating element (A4604).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are in pain from an improper brace. The Plan 
denied your request. The Plan says a similar study was recently performed, and it showed the enrollee's 
physician what was needed to treat the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the MRI of the lumbar 
spine is not medically needed for routine fracture follow up. There are no new neurologic changes documented. 
X-rays or a computed tomography (CT) scan is more appropriate. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. 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 January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 48 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 59.4 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96138). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that you want the services approved in 
order to provide a clearer and more definitive diagnosis for the enrollee. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for coverage. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation shows this enrollee had magnetic resonance imaging 
(MRI) performed but has had no cognitive screening tests performed. This testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, however this enrollee does not meet 
the criteria for neuropsychological testing as the day treatment will not be impacted by this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132, 96138).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve the VIA Disc allograft intervertebral disc augmentation procedure. You say 
that this service is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental. 
 
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 VIA Disc allograft intervertebral 
disc augmentation procedure. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found this service is considered experimental. 
 
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 VIA Disc allograft intervertebral disc augmentation procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the VIA Disc allograft 
intervertebral disc augmentation procedure (0627T).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832), provided on August 9, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832), provided on August 9, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 22, 2022, to 
July 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 22, 2022, to July 
20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on July 21, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the records attached support the 
services provided 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 a skilled nursing facility 
visit provided on July 21, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99213, 99214 and 80307. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 81002.  
 
You asked the Plan to pay for services provided from June 14, 2022, to August 9, 2022. You say that these 
services are supported in the medical records. The Plan says that the payment for code 81002 is included in the 
payment for code 80307. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99213, 99214 and 
80307.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99213, 99214 and 80307.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81002. 
 
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 81002 
is a column II code to column I code 80307. 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 the services described by procedure code(s) 81002. 
 
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Pregabalin capsule. 
 
You asked the Plan to pre-approve Pregabalin. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Pregabalin 
capsule.  
 Benefits for Pregabalin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 6, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
told by the provider you can disregard the bill you received however you received another bill. You also say 
that the claim needs to be paid since you are a dual member. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 6, 2022.