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

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 17, 2021, to November 29, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim was not submitted with required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not billed with the required Q and G codes. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee from November 17, 2021, to November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve benefits for a service dog. 
 
You asked the Plan to pre-approve benefits for a service dog. You say that this emotional support animal is 
necessary for you. The Plan denied your request. The Plan says you do not qualify for the service dog support 
benefit. 
 The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. The contract 
with the Plan covers a $500 allowance per calendar year for canine food and supplies for an ADA service dog 
when supporting documentation is received. 
 
We looked at the file and Medicare rules. The file shows that an emotional support animal is being requested. 
This is not covered by Medicare. The supplemental benefit with the Plan covers up to $500 per calendar year   
for the purchase of canine food and supplies only for members with an ADA service dog and cannot be used to 
purchase a service animal itself. Furthermore, the emotional support animal is not an ADA certified service 
animal. Therefore, we decided that the Plan does not have to pre-approve benefits for a service dog.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of the 
enrollees height, weight or body mass index. There is no discussion of scoliosis of the lumbar spine and/or the 
Cobb angle. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2020. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says a corrected claim 
must be receive within one year (12 months) from the processed date of the original claim submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until February 11, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 2, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services were rendered in good faith and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that POS code 31 should be used for a skilled nursing 
facility when the patient is in a Part A-covered stay.  POS code 32 should be using for a long-term nursing 
facility when the patient is not in a covered stay. 
 
In this case, you billed with POS 31.  However, the patient was not in a covered stay at the nursing facility after 
December 6, 2021.  So, POS 32 should have been used on this claim instead. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that 
the Plan does not have to pay for medical services provided on January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 20, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to a new dentist 
because your previous dentist advised they would not accept your insurance plan any longer. You also say that 
your documents show that an exam with a provider as a new patient should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injections and administration of the drugs 
provided on January 12, 2022. 
 
You asked the Plan to waive the cost share for injections and administration of the drugs. You say that this 
service should be covered. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 20% 
coinsurance for Medicare-covered Part B drugs and $250 copayment for Medicare covered surgery or other 
services. 
 
 You have been asked to pay $1,438.74 which is 20% of the allowed amount for injections and administration 
of the drugs. The allowed amount is $7,273.21 (20% x $7,273.21 = $1,438.74). You also have been asked to 
pay $36.58 which is less than the standard $250 copayment for the Medicare covered services. Injections and 
administration of the drugs falls within the Medicare Part B Prescription Drugs benefit category. The Medicare 
covered services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 cost share 
for injections and administration of the drugs provided on January 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided from January 28, 
2022, to February 15, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the PT services. You say that the enrollee is entitled to all Medicare approved 
services. The Plan denied your request. The Plan says services from out-of-network providers are not covered 
unless preauthorized. 
 
  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 physical therapy (PT) services provided from 
January 28, 2022, to February 15, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided May 7, 
2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are providing the medical 
records to support the necessity of the services in dispute. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low back surgery from lumbar level L2 to sacral S1. 
 
You asked the Plan to pre-approve the surgical procedure. You say that that you disagree with the statements 
made in this denial and ask for reconsideration. The Plan denied your request. The Plan says he records do not 
support the medical necessity of the requested procedure as the medical policy 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of a recent physical exam that shows neurologic 
impairment that correlates with imaging studies. More clinical info is needed including info on the degree of 
the enrollee's functional impairment. 
 
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 low back surgery from lumbar level L2 to sacral S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left shoulder surgery. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 that detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The documentation does not corroborate any recent 
physical therapy having been tried and failed for the left shoulder. The objective examination findings do not 
corroborate significant pathology that would require surgical intervention in place of conservative 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 left shoulder arthroscopy surgery 
rotator cuff repair and decompression of subacromial space with partial acromioplasty with coracoacromial 
ligament release when performed, 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left shoulder surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
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 step therapy requirement is not met. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 iron deficiency anemia 
in the setting of breast cancer. She has not tried and failed the Plan's required drug, Venofer. The records do not 
show that the required drug would be contraindicated or less effective; therefore, Injectafer is 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 Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on August 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6219 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code A6219. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A6219 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6219 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6219 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6219 billed for date of service February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that per Medicare guidelines the services rendered 
are payable. The Plan denied your request. The Plan says the rendering and referring provider are both OON 
providers and there was no approved authorization. 
  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 the surgery services provided on March 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on March 20, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that this service should be 
covered because the ambulance ride the day prior was covered.  You said that the emergency medical 
technician that showed up advised that you did not need to be transported. The Plan denied your request. The 
Plan says non-transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on March 20, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for non-transport ambulance 
services provided on March 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these 
services. 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 the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation provided on March 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency transportation. You say that you are requesting a retro 
authorization for the service rendered. The Plan denied your request. The Plan says there was no approved 
authorization for the service that was rendered. 
  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 Plan contract also says that prior authorization is required 
for non-emergency transportation. 
 
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 non-emergency transportation provided on March 
3, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 9, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were advised there 
would not be a copay applied if the transportation was for emergency services. 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 each ground ambulance transport.  
 
You have been asked to pay a $250 copayment for an ambulance transport. Ambulance services fall within the 
Ambulance 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 the ambulance 
services provided on May 9, 2022.