Persius/hicric huggingface dataset:
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 this procedure is minimally invasive 
and a safer alternative. 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 interspinous process spacers remain experimental. More research is needed to show safety 
and efficacy. Therefore, the requested services are 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray provided on February 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an X-ray. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an X-ray provided on February 14, 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 an office visit provided on October 14, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on October 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurosurgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the other providers are not using deep brain 
stimulation for central pain syndrome. The Plan denied your request. The Plan says there are in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurosurgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary for 
you to use while traveling outside your home. The Plan denied your request. The Plan says there is no 
documentation the current item is not meeting your needs. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is specifically being requested for use outside of the home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for {{enter specific services at issue}} provided on November 
30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that the patient is in a nursing home for which you have an exclusive contract with, which means only 
you can go into the facility to perform service for the patient in need. The Plan denied your request. The Plan 
says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 {{enter specific services at issue}} provided on 
November 30, 2021 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 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 office visit 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 waive the copayment for chiropractic services provided on January 
13, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that the was a customary 
visit and should be covered. 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 $15 
copayment for each chiropractic service visit.  
 
You have been asked to pay a $15 copayment for the chiropractic services. The 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 waive the copayment for chiropractic 
services provided on January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face mask (A7030), purchased on October 23, 2021. 
 
You asked the Plan to pay for the face mask. You say that the item should be covered. The Plan denied your 
request. The Plan says you obtained this item through a supplier that is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the face mask (A7030), purchased on 
October 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services at the Diagnosis Related Group 
(DRG) originally billed. 
 You asked the Plan to pay for the hospital services at the DRG originally billed. You say that this diagnosis 
code was billed correctly. The Plan denied your request. The Plan says the DRG billed was not supported 
because the primary diagnosis code of A41.9 (sepsis, unspecified organism) is not supported in the medical 
record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis of A41.9 (sepsis, unspecified 
organism). 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 hospital services at the DRG 
originally billed. Our reviewer says that a primary diagnosis of A41.9 (sepsis, unspecified organism) is not 
supported in the medical record. Our physician reviewer found the documentation supported an admission for 
calculus of gallbladder. From the information that was received, the documentation was inconsistent regarding 
a diagnosis of sepsis. Even though sepsis is documented in the discharge summary and progress notes, 
supporting medical record documentation was not found within the record. The patient was an 88 year old male 
with a past medical history of hypertension, dementia, and coronary artery disease who presented to the 
emergency room with right upper quadrant pain and nausea. Vital signs and testing showed signs consistent 
with acute cholecystitis. He was treated with IV antibiotics and percutaneous cholecystostomy tube. While the 
patients presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-
threatening organ dysfunction due to a dysregulated host response to infection. There was no evidence of 
significant physiologic instability. Therefore, the medical record received and available for review does not 
support the condition treated as consistent with a systemic infectious process.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services (CPT code G0299) from June 
10, 2022, through August 2, 2022. 
 
You asked the Plan to pre-approve the home health services. You say that you can get around a little bit but 
take supreme effort for you to do so. You state the physical therapy was helping you. You state that you need 
more physical therapy for mobility and a better quality of life. The Plan denied your request. The Plan says 
your request is not medically necessary because your records show you do not have a skilled need, your 
therapy level is independence for transfers, walking with a gait aid and bed mobility is supervised.  
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 the home health services. Our physician 
reviewer found there is no documentation that further skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. Provided records 
document that as of May 18, 2022, you were independent for transfers and was set-up assist for ambulation 
with a rolling walker, having met your short-term goals and some of your long term goals. Given the therapy he 
has had already, further utilization of the home exercise program appears appropriate at this point. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health services (CPT code G0299) from June 10, 2022, through August 
2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza (CPT code J7336). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have a medically accepted diagnosis for the use 
of this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that the Qutenza meets Medicare criteria for medically reasonable and necessary for the patient. 
Medically accepted indications for Qutenza include management of neuropathic pain associated with 
postherpetic neuralgia and diabetic peripheral neuropathy of the feet in adults. The enrollee does not have 
documentation of either of these covered conditions. 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 medication have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Qutenza (CPT code J7336).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sterilization procedure (58670). 
 
You asked the Plan to pay for the sterilization procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for a 
sterilization procedure (58670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
the endodontic therapy, of the anterior tooth (excluding final restoration) (D3310), and the removal of residual 
tooth roots (D7250) provided on January 25, 2022 and February 17, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
core buildup, including any pins when required (D2950), the endodontic therapy, of the anterior tooth 
(excluding final restoration) (D3310), and the removal of residual tooth roots (D7250) provided on January 25, 
2022 and February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the follow-up visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you had a previous visit with the 
requested provider and had treatments. The Plan denied your request. The Plan says you had an office visit on 
August 11, 2021, and the recent one is on May 18, 2022. The Plan states both of the visits were self-referred 
and had no authorization from your medical group. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the follow-up visit to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pathology services provided on January 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Pathology services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the rendering and referring provider are OON and 
there is no evidence that this is urgent or emergent. 
 
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 Pathology services provided on January 19, 2022 
by an out-of-network (OON) provider.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and there are no issues for which LTACH would offer a therapeutic advantage. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 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 unlisted ambulance services provided on December 3, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that you received a bill for the services you 
received. You say that a plan representative advised the ambulance services were paid. You say that you did 
not have a choice for which ambulance you took. You also say that you should not have to pay this bill. The 
Plan denied your request. The Plan says paramedic intercept services are only payable when all three 
conditions are met. The Plan also says that the ALS paramedic intercept services did not occur in a rural area. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the unlisted 
ambulance services provided on December 3, 2021.