Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you did not know prior authorization was required. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no approved authorization. Also, the services rendered was not 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 an office visit provided on September 17, 2021, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on September 7, 2021. 
 
You asked the Plan to pay for wound care. The Plan denied your request. The Plan says the non-contract 
provider must obtain prior authorization to provide services to our members. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for wound care provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychological testing evaluation services 
(96130) provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for the psychological testing evaluation services. You say that the 
services should be covered as the Plan's contract states there is a $40 copayment. The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $65 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $65 copayment for psychological testing evaluation services. Psychological 
testing evaluation services 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 psychological testing evaluation 
services (96130) provided on December 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided on April 
22, 2021 to August 2, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the medical records clearly reflect the 
medical necessity for the services rendered. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being 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 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 individual psychotherapy services (90837) 
provided on April 22, 2021 to August 2, 2021 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 the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 patient is a 72-year-old male who was admitted to the acute care hospital 
with cerebrovascular accident requiring thrombectomy but complicated by gastrointestinal bleed, multiple 
chronic wounds, pneumonia, lung effusion, and acute respiratory failure requiring mechanical ventilation 
support, antibiotics, wound care, and thoracentesis. Trach and percutaneous endoscopic gastrostomy were 
placed. Recent notes describe the patient as following commands with right side neglect, undergoing 
occupational and physical therapy, requiring ongoing tube feeds, but with normal white blood cell count and 
improving vitals. The patient appears to be more stable and improving but requires only short-term additional 
acute care services to further stabilize that can safely be administered at the current facility for the time being. The patient does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time. 
Transfer to a lower level of care may be considered when the patient is more stable and when treatment is 
completed. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Velcade. 
 
You asked the Plan to pre-approve Velcade. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been 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 Velcade. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
generic bortezomib intravenous before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects 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 Velcade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Velcade.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that you need a more 
accurate assessment of your blood sugar throughout the day. The Plan denied your request. The Plan says the 
requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
  
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 28, 2021. 
 
You asked the Plan to reduce the copayment for the emergency ambulance services. You say that in the past 
you were charged on $90 for ambulance services. The Plan denied your request. The Plan says the copayment 
was applied 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 $290 
copayment per date of service regardless off the number of trips by ground ambulance. 
 
 
 You have been asked to pay a $290 copayment for the emergency ambulance services. The emergency 
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 reduce 
the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and 
ground mileage (A0425) provided August 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair, group 3 standard, sling/solid seat/back, patient 
weight capacity up to and including 300 pounds (CPT code K0848), and accessories (CPT code(s): E1028, 
E2607, E2361). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says that there is a least costly alternative power wheelchair which can provide the needed 
and appropriate therapeutic benefit for you. The Plan states the records sent to the Plan by their provider 
showed that their mobility needs (the ability to move from place to place to complete an activity or task) were 
not met with a Jazzy 600 ES power wheelchair at the rehabilitation facility. The Plan states the Jazzy 600 ES 
power wheelchair is a group 2 type power wheelchair, and the Q6 Edge 3S-SS power wheelchair requested is a 
group 3 type power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the enrollee has a mobility deficit that impairs MRADLs in the home and cannot be ameliorated with a 
walker, cane, manual wheelchair due to weakness and impaired balance. The documentation notes that the 
enrollee can safely operate the requested power wheelchair. The enrollee has a mobility deficit due to a Group 
3 qualifying diagnosis. The November 9, 2021, letter of medical necessity from the physician and therapist is 
for the K0848 power wheelchair. The request for the K0848 power wheelchair with accessories is reasonable. 
 
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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 
pounds (CPT code K0848), and accessories (CPT code(s): E1028, E2607, E2361).  
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 21, 2021. 
 
You asked the Plan to pay for the services provided. You say that in-network benefits should be honored. The 
Plan denied your request. The Plan says there is insufficient documentation to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that 
CPT code 97110 is not supported in the medical record. The records show that the enrollee received physical 
therapy services at home. There is a more appropriate code for the services provided. 
 
 Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on 
July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 17, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was submitted with the incorrect 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met.  
 Specifically, the claim was submitted with the laboratory place of service code while the records suggest that 
the member's face-to-face service was rendered in an office sitting. It is not appropriate to bill the laboratory 
place of service code in this case. Therefore, we decided that the Plan does not have to pay for the drug testing 
services (G0483) provided on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with 
contrast (74160). 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the requested CT scan of the 
abdomen is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the 
abdomen does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the CT of the abdomen 
and pelvis of October 8, 2021 was negative for pancreatic mass in the face of multiple pulmonary nodules. The 
order for magnetic resonance cholangiopancreatography (MRCP) has not been placed. So, further workup is 
indicated but the recommendation of the oncologist for further workup has not yet occurred. 
 
 
 
 
 
  
 
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 scan of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with contrast (74160).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tegretol XR 200 mg tablet. 
 
You asked the Plan to pre-approve Tegretol XR. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tegretol XR 200 mg tablet.  
 
Benefits for Tegretol XR may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral sacroplasty (0201T). 
 
You asked the Plan to pre-approve a bilateral sacroplasty. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is not covered by Medicare or 
the Plan because sacroplasty is unproven and 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 a bilateral sacroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found sacroplasty remains experimental for sacral insufficiency fractures. More research is 
needed. 
 
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 bilateral sacroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bilateral sacroplasty (0201T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with contact guard assistance and is stand-by to minimum assist for transfers. You do not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.