Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 10, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, an authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error. 
 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 therapeutic exercises (97110) provided on May 
10, 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 lumbar epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve lumbar ESI services. You say that the records provided support the need for 
the requested injection services. The Plan denied your request. The Plan says lumbar epidural steroid injections 
are not recommended for non-acute axial back pain without a radiuclar component, acute or non-acute back 
pain in the absence of significant radicular symptoms, or lumbar axial pain or non-radicular pain syndromes. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI services are covered when medical 
necessary and when certain coverage criteria have been met.  
 
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 lumbar ESI services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a suggestive 
clinical presentation of lumbar radiculopathy.  She underwent bilateral L4-L5 lumbar transforaminal epidural 
steroid injection (TFESI) on November 23, 2021, which resulted in 60% decrease in pain for a period of 3 
weeks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar ESI services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injection (ESI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided October 11, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you needed multiple appointments to resolve 
dental issues and were displeased with your previous dentist. The Plan denied your request. The Plan says the 
frequency limit has been exceeded for this service. 
 
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. The Plan covers the limited 
oral exam once per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on August 17, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ankle surgery. 
 
You asked the Plan to pre-approve the ankle surgery. You say that this procedure is medically necessary due to 
foot pain and swelling. The Plan denied your request. The Plan says insufficient information was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ankle surgery. have been met. Limit 
clinical records were provided and the codes requested by the provider are for hip surgery. The records show 
the physician has ordered physical therapy and not surgery. Therefore, we decided that the Plan does not have 
to pre-approve ankle surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous sedation (D9243), an extraction (D7140), 
alveoplasty (D7310), and panoramic radiographic imaging (D0330) provided by an out-of-network provider on 
January 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you did not drop your dental insurance. The Plan 
denied your request. The Plan says the dental work that was provided has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
intravenous sedation (D9243), an extraction (D7140), alveoplasty (D7310), and panoramic radiographic 
imaging (D0330) provided by a participating provider on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 28, 2021, they reviewed their records and determined that was due to an 
administrative error.  
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 therapeutic exercises (97110) provided on June 
21, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 decreased responsiveness, fever, septic shock and 
profound pancytopenia in the setting of chemotherapy for rhabdomyosarcoma. The record indicates that the 
enrollee has had a complicated hospital course and requires ongoing acute care services. The enrollee continues 
to receive acute care services, and these have not been denied. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on April 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service, 
February 18, 2021, for the same procedure was partially paid. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar services 
rendered on February 18, 2021, they reviewed their records and determined that was due to an administrative 
error. 
 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 therapeutic exercises (97110) provided on April 
21, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a transthoracic echocardiography to be provided by the requested out-of-
network provider. The Plan denied your request. The Plan says the available medical information does not 
support the need for an authorization to a non-Plan provider, such as a lack of this specialty provider in the 
Plans network or an urgent/emergent situation that requires the services of a non-plan provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve a transthoracic echocardiography to be provided by the requested 
out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto, 20mg tablets. 
 
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says this medication falls 
under Part D coverage and the member does not have Part D benefits. 
 
  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 Xarelto, 20mg tablets.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you never received 
any services on this date. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The records provided by the hospital show that you were evaluated by a physicians assistant. 
 
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 an $85 
copay for each Medicare-covered emergency room visit.  
 
 You have been asked to pay an $85 copay for the emergency room services. The emergency room services fall 
within the Emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency room services provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient surgery facility services on 
September 1, 2021 to September 22, 2021. 
 
You asked the Plan to waive the copayment for Outpatient surgery facility services. You say that that there was 
no observation, or an extra facility room used for the 15 minute procedure. The Plan denied your request. The 
Plan says the cost share 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 $295 
copayment per day for Outpatient surgery facility services.  
 
 
 You have been asked to pay a $295 copayment per day for Outpatient surgery facility services. Outpatient 
surgery facility services falls within the Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for Outpatient surgery facility services on September 1, 2021 to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee and 
would like reconsideration of payment on the claim. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider. Also, the 
services performed are readily available in-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 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 November 18, 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 wound care to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve wound care to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says does not cover non-emergency services by a non-contracted provider 
when a contracted provider can provide the services. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve wound 
care to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that your facility is not responsible for obtaining 
prior authorization. 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 laboratory services provided on November 4, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (22514 and 
22515) with a bone biopsy and fluoroscopic guidance. 
 
  You asked the Plan to pre-approve a percutaneous vertebral augmentation (22514 and 22515) with a bone 
biopsy and fluoroscopic guidance. The Plan denied your request. The Plan says the member does not meet the 
coverage criteria because the MRI performed did not document any bone marrow edema. 
 
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 percutaneous vertebral augmentation 
(22514 and 22515) with a bone biopsy and fluoroscopic guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the LCD supports kyphoplasty when there is documented bone marrow edema on the MRI or bone 
scan/SPECT/CT uptake. The MRI did not demonstrate this finding and there was no documentation of a bone 
scan/SPECT/CT uptake having been performed. Additionally, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. 
 
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 percutaneous vertebral augmentation (22514 and 22515) with a bone biopsy 
and fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a percutaneous vertebral augmentation (22514 and 22515) with a bone biopsy and fluoroscopic guidance.