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

 
We decided that the Plan does not have to pre-approve an insertion of tunneled central venous access device to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the insertion of tunneled central venous access device. You say that the 
enrollee is an emergency inpatient admission and there are no in-network providers located in the service area 
and the enrollee is not medically stabled to be transported to Texas. The Plan denied your request. The Plan 
says the enrollee traveled out of state for care, and it was not an emergency for the enrollee to seek treatment 
out of state from an OON provider. Also, there are in-network providers who the enrollee can receive care 
from. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 insertion of tunneled central venous access device. Our reviewer says 
that the service is not medically necessary from an OON provider. Our physician reviewer found that the 
enrollee traveled to Washington state because he and his family reported that they were not satisfied with the 
care the enrollee was receiving in Texas. The documentation supports that the plan has the ability to care for 
the enrollee in network. 
 
The plan provides coverage for emergency care or urgently needed care from an out-of-network provider; this 
does not require prior authorization. If an enrollee requires medical care that in-network providers cannot 
provide, care from an out-of-network provider will be covered. Authorization should be obtained from the plan 
by your provider prior to seeking care from an out-of-network provider. 
 
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 insertion of tunneled central venous access device from an OON provider 
have not been met.  
 
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 the insertion of tunneled central venous access device. 
Therefore, we decided that the Plan does not have to pre-approve an insertion of tunneled central venous access 
device to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy; colpopexy (57425), and laparoscopy, 
removal of adnexal structures (58661) provided on February 8, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the provider in this case was the only assistant 
available at the time of the procedure. You say that the services were specifically requested by the in network 
primary care physician (PCP) and in network facility. You also say that the enrollee had no choice for an in 
network assistant. The Plan denied your request. The Plan says the provider specialty for the rendering provider 
in this case indicates a Registered Nurse First Assistant. The Plan also says that this provider specialty is not 
payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare makes payment for an assistant at 
surgery when the procedure is authorized for an assistant and the person performing the service is a physician, 
PA, NP, CNS.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Specifically, the provider specialty in this case is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pay for the laparoscopy; 
colpopexy (57425), and laparoscopy, removal of adnexal structures (58661) provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation service from May 2, 
2022, to May 3, 2022. 
 
You asked the Plan to waive the copayment for hospital observation service. You say that you found this 
amount was charged to you because your admission was an observation rather than a complete admission. You 
also say you were not informed of this at the time of your admission or any time during your stay. You also say 
you do not feel you should have to pay for this since it was never communicated to you. The Plan denied your 
request. The Plan says you were 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 $60 
copayment for outpatient hospital observation services.  
 
You have been asked to pay a $60 copayment for hospital observation services. Hospital observation services 
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 hospital observation service from May 2, 2022, to May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation provided on February 1, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient consultation. You say that the plan should have obtained prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services. 
 
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 inpatient consultation provided on February 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have complex medical or rehabilitation needs. 
 
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 physician reviewer found 
that the enrollee as hospitalized after a fall and found to have a rapid heart rate. He was treated without 
additional complications. he has a history of falls. The occupational therapy (OT) evaluation found he was at a 
supervision level for toilet hygiene, eating and functional transfers.  The physical therapy (PT) evaluation found he required moderate assistance for transfers and ambulation but 
noted enrollee required less than 25% support. There are inconsistencies between OT and PT assessment but no 
evidence of complex or intensive or specialized need. He is deconditioned at a modest level likely chronically 
with some acute exacerbation related to his acute illness. His orthostatic hypotension is less symptomatic and is 
being managed with an outpatient regimen. His deconditioned rehabilitation needs are such as to be managed at 
a lower level of care rather than an acute inpatient stay. The enrollee's condition does not require intensive or 
complex services and does not require frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyeglasses provided on February 21, 2022. 
 
You asked the Plan to pay more for the eyeglasses. The Plan denied your request. The Plan says the benefit 
maximum has been reached. 
 
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 up to a total of $250 every 2 years for eyeglasses. 
 
We looked at the file and the Plan's rules. The record shows that you received glasses on January 13, 2021, 
which the Plan paid $155 for, and the remaining balance of $55 was exhausted on February 21, 2022. Based on 
this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, 
we decided that the Plan does not have to pay more for the eyeglasses provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 31, 2022, 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 office visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a non-covered 
test. 
 The Plan must follow Medicare rules. Medicare rules say that to report a pharmacogenomics testing service, 
the requested claim information must be submitted.  
 
We looked at the file and Medicare rules. The records do not show that the claim was billed with the 
appropriate DEX Z-Code for payment to be considered. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the genetic testing provided on February 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 14, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the doctor should not be penalized 
for the hospital staff's failure in obtaining authorization for these services. The Plan denied your request. The 
Plan says a valid authorization was not found on file for the service in question. 
 
  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 subsequent nursing facility care provided on 
January 14, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Electromyography and a Nerve conduction study. 
 
You asked the Plan to pre-approve an Electromyography and a Nerve conduction study. The Plan denied your 
request. The Plan says these services do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve an Electromyography and a Nerve 
conduction study. Our reviewer says that an Electromyography and a Nerve conduction study are not medically 
necessary. Our physician reviewer that the records provided for review were limited to the findings of a 
neurological physical examination. The subjective portion of the chart note was blank. Based on the lack of 
subjective complaints, it cannot readily be determined why the requested testing has been ordered or why it is 
ultimately being requested. There was no indication that testing was ordered for an indication for which its use 
is supported in the LCD. In as much, this service cannot be adjudged to be reasonable and 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 an Electromyography and a Nerve conduction study have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Electromyography and a Nerve conduction 
study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261) and an Auto 
Emersion therapy mattress (E1399). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and a therapy mattress. You say that without the 
requested mattress, the enrollee will have to be institutionalized to get her health safe because she is currently 
lying on a broken air fluidized bed. The Plan denied your request. The Plan says the enrollee already has a 
specialty bed that is not more than 5 years old and which the plan has agreed to repair. In addition, the Emerg 
Auto Emersion mattress has deluxe features that are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an air fluidized bed (E0194). An air fluidized bed (E0194) serves the same 
purpose as a semi-electric hospital bed and a therapy mattress. Please note, records show the Plan has agreed to 
repair the broken air fluidized bed. Therefore, we decided that the Plan does not have to pre-approve a semi-
electric hospital bed (E0261) and an Auto Emersion therapy mattress (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on December 11, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RFA (CPT code(s): 64636 and 64635). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the injections have not been met. The medical record shows the 
enrollee has already undergone two lumbar region RFA sessions in the last 12 months first being on September 
22, 2021, and second being on October 18, 2021, according to the information reviewed on appeal, the 
requested service is not covered. The rules say for each covered spinal region no more than two (2) RFA 
sessions will be reimbursed per rolling 12 months. Therefore, we decided that the Plan does not have to pre-
approve the RFA (CPT code(s): 64636 and 64635).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be completed at the current facility until more appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) crowns (D2740), four (4) periodontal scaling 
and root planing, four or more teeth per quadrant (D4341) and local anesthesia in conjunction with operative or 
surgical procedures (D9215). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have dental work done but are 
allergic to Caines, so you require sedation for the work to be completed. Your dental provider told you they 
cannot complete the requested dental services due to your allergies and referred you to see the requested dental 
provider. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve two (2) crowns (D2740), four (4) periodontal 
scaling and root planing, four or more teeth per quadrant (D4341) and local anesthesia in conjunction with 
operative or surgical procedures (D9215).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left SI joint injection (CPT code 27096). 
 
You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your 
request. The Plan says your records do not show that you have document tenderness over the upper aspect of 
your sacroiliac joint (Fortins point) or positive results of 3 stress tests of your sacroiliac joint. 
 
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. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
diagnosis of SI. There are no clear objective findings supporting SI joint dysfunction. Multiple other pain 
generators are evident. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested left sacroiliac joint 
injection (CPT 27096), in this case, 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the left SI joint injection (CPT code 27096).