Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 14, 2022, to 
March 18, 2022. 
 
You asked the Plan to pay for home health care. You say that these services were billed correctly on the right 
type of bill. The Plan denied your request. The Plan says the type of bill submitted for these services is 
inappropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that all HH PPS claims must be submitted with Type of Bill (TOB) 0329. 
 The Home Health claim in this case was submitted with TOB 0323. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pay for home health services provided from March 14, 2022, to March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 August 30, 2021 by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric (Hoyer) lift. 
 
You asked the Plan to pre-approve a Hoyer lift. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
 
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 Hoyer lift. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the documentation does not 
support that you require another, electric, Hoyer lift. There is a Hoyer lift at the AFH that is being used for 
transfers for you. It is unclear why a second electric lift is required. 
 
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 Hoyer lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electric (Hoyer) lift.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pre-admission testing provided on July 7, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the pre-admission testing provided on July 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the podiatry service. 
 
You asked the Plan to pre-approve a podiatry service. You say that there are no in-network doctors available. 
The Plan denied your request. The Plan says the authorization was denied because the request was for a non-
contract provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the podiatry service.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of a large joint with a viscosupplementation. 
 
You asked the Plan to pre-approve injection of a large joint with a viscosupplementation. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan 
(Hymovis).  
 
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 injection of a large joint with a 
viscosupplementation. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, the record indicates that you have painful knees following a fall that is attributed to 
osteoarthritis. The record does not contain sufficient medical records addressing the coverage criteria to 
establish that the criteria for coverage have been satisfied. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of a large joint with a viscosupplementation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve injection of a large joint with a 
viscosupplementation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tornado allograft. 
 
You asked the Plan to pre-approve a Tornado allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a Tornado allograft a Tornado allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Tornado allograft remains experimental. More research is needed. 
 
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 Tornado allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Tornado allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (71250) 
provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $130.16 copayment for the CT scan, which is less than the standard $150. CT 
scans fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT) scan (71250) provided on 
April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you do not have a condition which requires continued 
inpatient hospital care with daily doctor visits for more than 25 days. 
 
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. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. All medically necessary care is being provided in the current acute care setting. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and pulmonary function tests are described as showing mild obstruction. He was 
recently admitted after taking an unknown pill provided by his neighbor and is on chronic narcotics for pain. 
The arterial blood gas (ABG) shows hypercarbic respiratory failure, consistent with respiratory depression 
from narcotic. There is no ABG done while stable as an outpatient to document chronic carbon dioxide retention. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you are requesting preauthorization for 
the Vertiflex procedure. The Plan denied your request. The Plan says this procedure is considered experimental 
and investigational. There is not enough studies to show Vertiflex Superion is safe and effective to treat back 
pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve insertion of Vertiflex Superion device (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, you did not require any skilled 
services on an inpatient basis, at a SNF level of care as of July 14, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the stereotactic computer-assisted procedure (61781) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the stereotactic computer-assisted procedure (61781). The Plan denied your 
request. The Plan says that procedure code 61312 was approved, and procedure code 61781 is inclusive to 
another billed code. 
 
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, the CPT Code Manual definition of 
code 61781 is stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in 
addition to code for primary procedure). 
 
We asked our coder 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 stereotactic computer-assisted procedure (61781). Our 
reviewer says that the documentation does support the use of add on code 61781. Our reviewer found there is 
no edit relationship between procedure codes 61312 and 61781 billed on the claim. A modifier is not needed, 
and the coding is correct. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stereotactic computer-assisted procedure (61781) have been met. Therefore, 
we decided that the Plan has to pay for the stereotactic computer-assisted procedure (61781) provided on 
December 9, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen for cluster headaches. 
 
You asked the Plan to pre-approve oxygen for cluster headaches. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that only those beneficiaries diagnosed with the condition 
of cluster headache are eligible for participation in a clinical study. 
 
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 oxygen for cluster headaches. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case you are 
not enrolled in a clinical trial for their cluster headaches. The request also appears to have otherwise been made 
for a portable unit (based on HCPCS codes). For both of these reasons the service requested would not be 
eligible for coverage at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen for cluster headaches have not been met. Therefore, we decided that the 
Plan does not have to pre-approve oxygen for cluster headaches.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for injections provided on August 22, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that it appeared the shots were 
prescription medicine and you expected only a small copay. The Plan denied your request. The Plan says that 
the coinsurance was applied correctly. 
 
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 submit an Explanation of Benefits or claim form to 
confirm what services were billed. This means that we cannot determine the cost you are being asked to pay is 
correct or justified by the Plan contract. It is the burden of the Health Plan to substantiate their decision with 
evidence. In this case, the decision has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to waive the coinsurance for injections provided on August 22, 2021.  
 
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 pay for psychotherapy provided on September 22, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a Marriage Family 
Therapist is not eligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient visit provided on 
March 1, 2022. 
 
You asked the Plan to waive the copayment for the outpatient visit. You say that you did not have hospital 
services performed. 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 $250 
copayment for outpatient hospital services.  
 
The file shows that the visit was billed with a hospital location code. Therefore, you have been asked to pay 
$117.53, which is less than the $250 copayment for the outpatient visit. The outpatient visit falls within the 
Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hospital 
outpatient visit provided on March 1, 2022.