Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable oxygen 
system (K0738). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable oxygen system. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage 
have not been met because the requested items represent a duplication of services. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an oxygen concentrator and a portable oxygen system. The requested items serve 
the same purpose as an oxygen concentrator and a portable oxygen system. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator (E1390) and a portable oxygen system (K0738).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested item have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the enrollee meets one of the criteria for a fixed height hospital bed and the enrollee's weight is more than 
350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty extra wide hospital bed have not been met. Specifically, the available medical records indicate that the enrollee's weight does not exceed 350 pounds. 
Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed 
(E0303).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have 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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is an 88-year-old male being treated for spinal stenosis of the lumbar 
region with neurogenic claudication. He presented with persistent low back pain and is still having a hard time 
standing for more than a few minutes and has pian into his legs. He feels better instantly when he sits down or 
leans forward. The exam reveals decreased range of motion in extension. There is midline tenderness at L4-S1. 
The pain radiates into the legs. Mild facet loading and tenderness. 
 
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. 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 L3-4 and L4-5 is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 2, 2022, to 
February 10, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the Notice of 
Admission (NOA) has not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must submit a Notice of 
Admission (NOA) for each series of home health period of care beginning with admission and ending with 
discharge.  
 
We looked at the file and Medicare rules. The required NOA has not been submitted to the Plan for 
consideration. Based on this information, we decided that Medicare rules for coverage of home health care 
have not been met. Therefore, we decided that the Plan does not have to pay for home health care provided 
from February 2, 2022, to February 10, 2022.
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 the enrollee is needing further acute 
services for recovery. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about the enrollee's condition they do not meet all the requirements. 
 
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 health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
provided on January 31, 2022. 
 
You asked the Plan to pay for the CT scan services.. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate modifier. 
 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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head and neck 
provided on January 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that you are appealing 
the denial of SNF admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollees condition they do not meet all the requirements. 
 
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 a skilled nursing facility (SNF) 
admission. Our reviewer says that there is no documentation that daily skilled services are required. Our 
physician reviewer found the enrollee is a 75 year old female with a past medical history of hypertension who 
presented to the acute hospital on July 9, 2022 with back pain due to a lumbar wedge compression fracture and 
post herpetic neuralgia. She is reported to be medically stable for discharge on outpatient medications. The 
enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a skilled nursing facility (SNF) admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on November 19, 2021. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. Medicare rules also say that panels of tests that include the BLM gene are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel provided 
included testing for the FANCC and BLM genes. This means the entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the NGS testing panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel 
provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the only doctor in your medical group did not 
treat you right. You say your doctor wants the allergy specialist to do some tests because of your candida 
albicans. 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 office visit to be provided 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 ultrasonic guidance for needle placement (76942) 
provided on October 5, 2021. 
  You asked the Plan to pay for the ultrasonic guidance for needle placement (76942). You say that the denied 
code should be reprocessed for payment. The Plan denied your request. The Plan says an appropriate modifier 
was not billed with this code edit. 
 
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 76942 
is a column II code to column I code 36556. 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 the ultrasonic guidance for needle placement (76942) provided 
on October 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on December 1, 
2021. 
 
You asked the Plan to pay for emergency care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee 
had elected hospice service so the Plan is not responsible for payment of this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit provided on December 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on December 31, 2021. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel provided 
included testing for the FANCC gene. This means the entire panel is not covered. Based on this information, 
we decided that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided on 
December 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from January 10, 2022, to January 
19, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because a Notice of Admission 
(NOA) was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that a Notice of Admission (NOA) is required for any 
series of home health periods of care beginning with admission and ending with discharge.  
 
We looked at the file and Medicare rules. The documentation does not include a NOA submitted to the Plan for 
consideration. Based on this information, we decided that Medicare rules for coverage of home health care 
have not been met. Therefore, we decided that the Plan does not have to pay for home health care provided 
from January 10, 2022, to January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tricuspid heart valve repair or replacement (TTVR). 
 
You asked the Plan to pre-approve TTVR. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the service at issue is considered investigational, unproven and 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 TTVR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on current clinical guidelines, there are insufficient randomized clinical data at this time 
to support the use of TTVR in this 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 TTVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve tricuspid heart valve repair or replacement (TTVR).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837) provided on 
November 4, 2021 to February 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-
authorized. 
 
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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for outpatient mental health services (90837) provided on November 4, 2021 
to February 21, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on December 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory work. You say that the service was medically necessary, and you are 
requesting reconsideration of the claim. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for laboratory work 
provided on December 27, 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 physician's services provided on December 7, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from a network provider with the exception of emergency care or urgently needed care from 
an out-of-network provider. 
 
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 physician's services provided on December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you had no say in picking 
emergency services because you were unconscious. 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 $250 
copayment for each Medicare-covered one-way trip via ground ambulance, for both in and out-of-network. 
 
 
  You have been asked to pay $250 for the ambulance services. 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 ambulance services 
provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments provided on May 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatments. You say that you are asking for 
reconsideration of the claim. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
chiropractic manipulative treatments. We found no exception that would require the Plan to pay for the 
chiropractic manipulative treatments. The records provided for review do not show that the services at issue 
were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatments provided on May 4, 2022, by an out-of-network (OON) provider.