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

 
We decided that the Plan does not have to waive the copayment for an EKG provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for an EKG. You say that you should not be responsible to pay 
this. 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 a $25 
copayment for other Medicare covered outpatient diagnostic tests and procedures.  
 
 
 
 
 You have been asked to pay $15.61 for an EKG, which is less than the standard $25 copayment for an EKG. 
This item/service falls 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 an electrocardiogram (EKG) provided on April 
1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hot and cold test (D0460) and a non-surgical blocked nerve 
canal treatment (D3331) provided by a participating provider on May 25, 2022. 
 
You asked the Plan to pay for a hot and cold test and a non-surgical blocked nerve canal treatment. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental 
services are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a hot and 
cold test (D0460) and a non-surgical blocked nerve canal treatment (D3331) provided by a participating 
provider on May 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that you live in constant pain. The Plan 
denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
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 requested services. Our physician 
reviewer found that you are being treated for spinal stenosis of the lumbar region with neurogenic claudication. 
Current evidence based medical guidelines and peer reviewed literature do not fully support the spinal 
decompression device procedure over the lumbar laminectomy. There is a lack of large volume, long-term 
peer-reviewed outcome studies to support the use of this device for your medical condition. There is no 
discussion of scoliosis of the lumbar spine, or documentation of the Cobb angle. There is no discussion 
indicating that a DEXA scan has demonstrated the lack of significant osteoporosis. There is no compelling 
rationale or extenuating circumstances to support the medical necessity of this request. Therefore, the requested 
Vertiflex interspinous device at L4-5 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy for the enrollee to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that network providers are available to provide 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 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 
physical therapy for the enrollee to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has been in the restorative therapy 
program and would benefit from PT or OT. The Plan denied your request. The Plan says that the records do not 
show that the enrollee requires these skilled services on a daily basis, nor that daily skilled services can be 
provided only on an inpatient basis in a SNF. 
 
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 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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 a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary. The 
Plan denied your request. The Plan says this item is not covered under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (88305) provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the claim is a duplicate. 
 
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. No documentation was provided to show that this service was duplicative. No 
documentation was provided by the plan to show that this service was previously paid. Therefore, we decided 
that the Plan has to pay for lab services (88305) provided on December 16, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of home care physical therapy. 
 
You asked the Plan to pre-approve continuation of home care physical therapy. You say that you still need 
physical therapy because your leg is getting worse and you are having trouble moving around and you get pain 
in your leg when you try to walk. The Plan denied your request. The Plan says continuation of home care 
physical therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continuation of home care physical 
therapy. Our reviewer says that continuation of home care physical therapy is not medically necessary. Our 
physician reviewer found that the requested therapy is generally accepted as a specific and effective therapy for 
weakness and gait instability. The most recent documentation dated July 19, 2022 indicated that your motor 
strength was 4/5 in the lower extremities and your were noted to be at your baseline level of function. You are 
at your baseline level of function and plateaued in terms of improvement. You may continue to require 
assistance with mobility and daily activities, but this does not require the services of a skilled physical 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of home care physical therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of home care physical therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have electrolyte derangement and renal failure, 
and you need a higher level of care. The Plan denied your request. The Plan says the request is not medically 
necessary. The services you need can be provided safely in other settings. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient visit provided on February 8, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient visit. You say that you were an inpatient and feel 
the outpatient copayment is incorrect/invalid. 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 a $40 
copayment for medically-necessary medical care or surgery services furnished in a physicians office, certified 
ambulatory surgical center, hospital outpatient department, or any other location. 
 
 
 You have been asked to pay a $40 copayment for an outpatient visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 an outpatient visit provided on February 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve forty (40) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have no other 
means for transportation. The Plan denied your request. The Plan says the request exceeds your benefit limit. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. The 37th trip and beyond is not a covered 
benefit. Your 2022 EOC says up to thirty-six (36) one-way trips, combined in and out-of-network, are covered each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-
approve forty (40) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0748) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item  
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator (E0748) to be 
provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic colonography (CTC) screening 
(74263). 
 
You asked the Plan to pre-approve a CTC screening. You say that a colonoscopy is too dangerous for your 
health. You also say you had this service done five years ago, and were able to have it done. The Plan denied 
your request. The Plan says your doctor ordered a special test that takes pictures of your bowels to screen for 
bowel cancer. The Plan also says that this request for a CT scan of the bowels is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage for colorectal cancer screening 
specifically includes screening CTC.  
 
We looked at the file and Medicare rules. The specific code requested is for a CTC screening. Based on this 
information, we decided that Medicare rules for coverage of a CTC screening have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomographic colonography (CTC) screening 
(74263).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on June 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says 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 to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure (64628).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) 
provided on May 18, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that these services were medically necessary 
as the enrollee is a fall risk, has been bed confined for years and is blind. The Plan denied your request. The 
Plan says the criteria for coverage of non-emergent ambulance transport are not met in this case, as the enrollee 
could have been safely transported in another vehicle on the date in question. 
 
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 ambulance transportation. Our reviewer says 
that the ambulance transportation was not medically necessary in this case. Our physician reviewer found the 
documentation does not support that the enrollee required the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transportation on May 18, 
2022. The enrollee was discharged from the emergency department after an evaluation and was transported to a 
skilled nursing facility. The enrollee was stable at this time and did not require basic or advanced life support services. The records also do not show that other means of transport were contraindicated for this enrollee on 
the date in question. A stretcher van would have been a reasonable means of transport. The documentation does 
not support that the ambulance transport on May 18, 2022, was medically reasonable and necessary for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) provided on May 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered.  
 
We looked at the file and Medicare rules. Per L33820, the requested total electric hospital bed is not covered. 
Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require 
transportation to get to dialysis. The Plan denied your request. The Plan says that only 30 one-way rides are 
covered per year. 
 
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 thirty (30) 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 trips.