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

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the requested service 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria only allows for low intermediate risk; therefore, the enrollee does not meet coverage 
criteria as high risk. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and chiropractic manipulative treatments 
provided by a chiropractor on November 11, 2021 and November 15, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that you went for manipulation which is what you 
got. The Plan denied your request. The Plan says the denial of payment for the office visit is correct, because 
this service is not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that 
the copayment amounts you are being charged for covered chiropractic services are correct. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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 $15 copayment for in-network covered chiropractic 
services. There were 2 visits, resulting in a total copayment amount of $30. 
 
The records show that the office visit at issue is not manual manipulation of the spine. You have been asked to 
pay $15 copayment for each in-network chiropractic visit. Chiropractic services fall within the Chiropractic 
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 pay for an office visit and chiropractic manipulative 
treatments provided by a chiropractor on November 11, 2021 and November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99202) provided August 26, 2021 to August 30, 2021.
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The Plan denied your request. The Plan says the code billed is non-covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (99202) provided August 26, 2021 to August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says a similar study to the one requested has already been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no medical 
records explaining the need for MRI in the first place. Secondly, according to your letter, the initial already 
approved MRI is to be done at one provider, but due to your claustrophobia you are requesting the MRI to be 
done on an open magnet. It is not known whether this second facility is an in-network provider. The first and 
already approved scan has not yet been done. 
 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the pelvis.
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 an LTACH is the medically appropriate admission for the continuation of medically necessary acute care services for the enrollee. The Plan denied your request. The Plan says the LTACH services you are requesting do not meet the requirements for approval.
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. Our physician reviewer found the enrollee was admitted with sepsis from wounds and was found down at home. The record indicates that the enrollee had acute kidney injury and although she is improving, still requires acute care services. Our reviewer found that the enrollee continues to receive acute care services, and these have not been denied. Our physician reviewer also found that the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on September 29, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says that the services require authorization and was not obtained. 
 
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 the transportation services. Our reviewer 
says that the transportation services were not medically necessary. Our physician reviewer found there was no 
specific clinical rationale warranting ambulance transport. The reviewer found that the documentation did not 
support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of 
vehicle) were contraindicated for the enrollee on September 29, 2021.  
 The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation 
did not support that the ambulance transport on 9/29/2021 was medically reasonable or 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 the transportation services have not been met. Specifically, the file did not 
support that other means of transport were contraindicated. Therefore, we decided that the Plan does not have 
to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage 
(A0425) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dye injection (38792) provided August 13, 2021. 
 
You asked the Plan to pay for the injection. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the billed code is inclusive to the primary procedure billed 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 CPT code. 
 
 
 
 
 
 We find that CPT code 38792 is not supported in the medical record. Specifically, this service is included in 
CPT 38900 which was also billed. Based on this information, we decided that Medicare rules for coverage of 
the injection have not been met. Therefore, we decided that the Plan does not have to pay for a dye injection 
(38792) provided August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel (0242U) 
provided on August 24, 2021. 
 
You asked the Plan to pay for code 0242U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel 
(0242U) provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that your health will decline if you are not cared 
for at the SNF, due to a bad stroke. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 
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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled 
nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided September 17, 2021. 
 
You asked the Plan to pay for the office visit. You say that the office visit was medically necessary. The Plan 
denied your request. The Plan says this service is 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 CPT code. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, this service is included in the 
osteopathic manipulation service that was also billed. The office visit was not separate and distinct from this 
service. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided 
September 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261). 
 
You asked the Plan to pre-approve a CT colonography. The Plan denied your request. The Plan says the 
ordered test is not medically necessary. The Plan also says that there is no documentation or rationale provided 
that would suggest that the use of a colonoscopy is not feasible or is contraindicated. 
 
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 a CT colonography. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the available record does not support that the enrollee's prior colonoscopies were 
incomplete or technically problematic. Our reviewer found that the available record does not support that the 
enrollee has a medical history or condition that absolutely contraindicates her to undergoing a diagnostic 
colonoscopy at this juncture. Our physician reviewer also found that the CT colonography as proposed for the 
enrollee is neither medically necessary nor appropriate in her 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 a CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic (CT) colonography (74261).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), the pressurized or non-pressurized 
inhalation treatment (94640), the therapeutic, prophylactic, or diagnostic injection (96372), the ketorolac 
tromethamine injection (J1885), and the albuterol (J7620) rendered by the out-of-network (OON) provider on 
July 28, 2021. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an 
out of network provider, without prior 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 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 
items/services 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 office visit (99204), the pressurized or non-
pressurized inhalation treatment (94640), the therapeutic, prophylactic, or diagnostic injection (96372), the 
ketorolac tromethamine injection (J1885), and the albuterol (J7620) rendered by the out-of-network (OON) 
provider on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that the records provided support the 
need for the services being requested. The Plan denied your request. The Plan says the clinical information 
provided does not show that it has been at least two weeks since the prior injection. 
 
The Plan follows Medicare rules. Medicare rules say that a second diagnostic block is indicated at 2 weeks if 
the first block provided 80% relief of primary pain. 
 
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 services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found a history of low 
back due to lumbar spondylosis. She has been treated with medical therapy including opiates. She underwent 
bilateral L3-L5 medial branch blocks (MBBs) on February 2, 2022, which provided 75% pain relief. She was 
scheduled to undergo her second bilateral L3-L5 MBBs on February 16, 2022. The first diagnostic block only 
provided 75% pain relief. 
 
 
 
 
 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 services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the continuous positive airway pressure 
(cpap) device (E0601), the sales tax (S9999), and the nasal application device (A7034) purchased from the  
out-of-network (OON) provider on August 31, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an 
out of network provider, without prior 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 issue reimbursement from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to issue reimbursement for these items. Additionally, the items 
were purchased from a provider that does not participate in the Medicare program. Therefore, we decided that 
the Plan does not have to issue reimbursement for the continuous positive airway pressure (cpap) device 
(E0601), the sales tax (S9999), and the nasal application device (A7034) purchased from the out-of-network 
(OON) provider on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on May 24, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on May 24, 
2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the hospital services. We decided that the Plan does 
not have to fully waive the copayment for the hospital services.  
 
You asked the Plan to waive the copayment for the hospital services. You say that you did not want to go to the 
hospital, but the fire department wanted to take you there. You say that you were not happy with the services. 
The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to reduce the copayment for the hospital services.  
 
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. There are no medical records showing you were admitting to the hospital as an 
inpatient. You acknowledge that you were seen in the emergency room. Therefore, we decided that the Plan 
has to reduce the copayment for the hospital services to the emergency room copayment of $90.  
 
We also decided that the Plan does not have to fully waive the copayment for the hospital services. 
 
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 $90 
copayment for an emergency room visit. Therefore, we decided that the Plan does not have to fully waive the 
copayment for the hospital services. 
 
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. 
 
Your complaint about not being happy with the service 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.