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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, and debridement 
services provided on February 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care and debridement services. You say that the 
enrollee was in a nursing home and could not choose a network provider. 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 
subsequent nursing facility care, and debridement services. We found no exception that would require the Plan 
to pay for the subsequent nursing facility care, and debridement services. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, and debridement services provided on February 
22, 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 February 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told by the Plan that the office visit would 
be covered after your move to a different state. You say you were not told that you would need a prior 
authorization. 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. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on February 18, 2022, by an out-of-
network (OON) provider.  
 Your complaint that the Plan representative was inadequate 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.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81201, 81408, 81162, 81406, 
81404, 81403, 81405, 81292, 81295, 81298, 81307, 81317, 81321, and 81407 provided on November 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 find that CPT codes 81201, 81408, 81162, 81406, 81404, 81403, 81405, 81292, 81295, 81298, 81307, 
81317, 81321, and 81407 are not supported in the medical record. Specifically, if a laboratory service evaluates 
multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of 
service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with 
algorithmic analysis, or proprietary laboratory analysis code. Review of the file does not support that the services provided were billed with only one code. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded 81201, 81408, 81162, 81406, 81404, 81403, 81405, 81292, 81295, 
81298, 81307, 81317, 81321, and 81407 provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 fractions of Proton Beam Therapy. 
 
You asked the Plan to pre-approve Proton Beam Therapy services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested Proton Beam Radiation 
therapy is not the standard of care at this time for the enrollee's condition. 
 
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 Proton Beam Therapy services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found radiation therapy can be considered medically necessary for lower grade 
gliomas when the need is sufficiently supported. However, in the absence of a compelling dosimetric (or 
evidence based) rationale, when other potentially equally efficacious forms of radiotherapy are available, there 
is no compelling rationale for why Proton Beam Therapy would be medically reasonable and necessary. The 
requested Proton Beam therapy would not be furnished in accordance with accepted standards of care in this 
case 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Proton Beam Therapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 30 fractions of Proton Beam Therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ultrasound provided on March 2, 2022. 
 
You asked the Plan to pay for a diagnostic ultrasound. You say that you are appealing the denial for services 
rendered. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 a diagnostic ultrasound provided on March 2, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty, right knee (27447). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has a severe joint disease 
and has tried conservative treatment. He is in pain and having a hard time doing activities of daily living. He 
has now developed afflication contracture. The Plan denied your request. The Plan says the records do not 
support that the requested knee arthroplasty meets the medically necessary 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee was being treated for primary osteoarthritis of both knees. He presented 
with bilateral knee pain. He notes the pain has been present for approximately 4 years, with a gradual onset. He 
reports popping and swelling. He was last seen in 6/2019 and given bilateral knee steroid injections. However, 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested right total knee arthroplasty (CPT 27447), 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total knee arthroplasty, right knee (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair services for a power wheelchair. 
 
You asked the Plan to pre-approve repair services for a power wheelchair. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
repair services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. During the reasonable useful 
lifetime, Medicare does cover repair up to the cost of replacement for medically necessary equipment owned by 
the beneficiary. 
 We looked at the file and Medicare rules. In this case, you are requesting repair services for a power wheelchair 
received by the enrollee in 2010. Therefore, the requested repair services are for an item that has outlasted its 
reasonable useful lifetime. A replacement would be appropriate in this case if demonstrated to be medically 
necessary. Based on this information, we decided that Medicare rules for coverage of repair services for a 
power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve repair 
services for a power wheelchair.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee's needs may be met in a less intensive setting of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a medical history cervical spine spondylosis with myelopathy. The enrollee was admitted to the hospital on June 28, 2022, for an anterior cervical disc fusion from C3-5 with 
removal of prior instrumentation at C5-7. Prior to being hospitalized the enrollee was noted to be modified 
independent in terms of his mobility and performing activities of daily living. The enrollee is currently 
requiring supervision for bed mobility and transfers. He is ambulating 200 feet with the walker with contact 
guard assistance to minimal assistance. Hes requiring contact guard assistance for toileting. The complexity of 
the enrollees nursing medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was recently hospitalized for cervical spine 
surgery. He does not have the medical complexity requiring physician and rehabilitation nursing oversight in 
the acute inpatient rehabilitation setting. He does not have complex medical issues and does not require 
complex wound care or bowel and bladder management. His medical and rehabilitation needs do not require 
the intensive interdisciplinary approach provided on acute inpatient rehabilitation. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. 
 
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 for the hearing aid (V5261) purchased on February 16, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you were told by a plan representative that your 
hearing benefit is available for up to $500 per ear, per year. The Plan denied your request. The Plan says your 
purchase exhausted the Plan's $500 benefit limit, and you are responsible for the remaining charges. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays up to 
$500 once every 36 months towards the cost of hearing aids.  
 
We looked at the file and the Plan's rules. The documentation shows that the provider billed the Plan $4,540 for 
the hearing aid purchased on February 16, 2022. The Plans allowed cost for this service was $978.90. This is 
the Plans discounted rate for this service and the amount the provider would accept as full payment. The 
record shows that the Plan has paid the total $500 allowance and you are being asked to pay the remaining 
$478.90 which exceeds this amount. Please note that the contract does not stipulate that this amount is to be 
provided per ear/hearing aid, but rather is a total amount. Based on this information, we decided that you have 
been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan 
does not have to pay for the hearing aid (V5261) purchased on February 16, 2022.  
 Your complaint about potential misinformation from a Plan representative or Plan-contracted provider 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 15, 2022. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim cannot be paid as billed. 
 
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 medical services provided on 
February 15, 2022, have been met. In this case, no medical records have been submitted with this claim to corroborate the services as billed. Therefore, we decided that the Plan does not have to pay for the medical 
services provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the debridement services provided on 
September 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the debridement services. You say that it was impossible to 
obtain authorization because the enrollee gave incorrect insurance information. You say 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 and the debridement services. We found no exception that would require the Plan to pay for the 
office visit and the debridement services. The records provided for review do not show that the services at issue 
were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and the 
debridement services provided on September 3, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve epidural. We decided that the Plan does not have to pre-approve 
facet joint injection.  
 
You asked the Plan to pre-approve epidural and facet joint injection. You say that the enrollee suffers from 
radiation low back pain. The Plan says that the denial of authorization for these services is correct, because the 
record does not show that the enrollee was unable to tolerate non-invasive care or 4 weeks of conservative care. 
 
We decided that the Plan has to pre-approve epidural.  
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered if certain 
criteria are met.  
 
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 epidural and facet joint injection. Our 
reviewer says that the enrollee meets the Medicare criteria for the requested epidural. Our physician reviewer 
found the enrollee has chronic low back pain and is taking medications. The enrollee has had physical therapy, 
a home exercise program, ice heat, and Medrol steroids. The enrollee has had pain for more than 4 weeks and 
has an acute sacral fracture. A transforaminal epidural steroid injection is medically 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 epidural and facet joint injection have been met. Therefore, we decided that the 
Plan has to pre-approve epidural.  
 
We also decided that the Plan does not have to pre-approve facet joint injection. 
 
The Plan follows Medicare rules. Medicare rules state that it is not considered medically reasonable and 
necessary to perform multiple blocks during the same session as ESIs.  
 
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 facet joint injection. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injection. Our physician 
reviewer found that facet joint injections may not be performed at the same session as an epidural steroid 
injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint injection. 
 
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.