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

 
We decided that the Plan does not have to pre-approve genicular nerve block services. 
 
You asked the Plan to pre-approve genicular nerve block services. You say that genicular nerve blocks are a 
Medicare benefit and are not experimental. The Plan denied your request. The Plan says medical studies 
haven't proven that genicular nerve blocks are helpful for treatment of the enrollee's health problem. 
 
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 genicular nerve block services. Our 
reviewer says that genicular nerve block services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of genicular nerve blocks in treating knee pain is still being studied 
in clinical trials and is considered experimental/investigational. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scans. 
 
You asked the Plan to pre-approve CT scans. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says these CT scans are not medically necessary. 
 
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 CT scans. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested CT scans. Our physician reviewer found records 
indicate the enrollee was diagnosed with microcytosis and chronic lymphocytic leukemia. Medical literature 
has stated that CT scans generally are not required for initial evaluation or follow-up and that staging does not 
use CT scans and relies on physical examination and blood counts. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scans.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on November 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you should not be penalized for the staff's 
failure to take proper steps in obtaining the authorization 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 had network providers 
available who could have provided the home health visit in this appeal. The Plan did not pre-approve the home 
health visit. We found no exception that would require the Plan to pay the home health visit. The records 
provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the home health visit provided on November 17, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a 
lower level of care such as at a skilled nursing facility. 
 
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 that the enrollee's rehabilitation needs can be met safely and provided at a lower intensity and alternate setting such as in a skilled nursing facility with intermittent therapies. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the office visit (99215) provided on  
January 4, 2022. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service 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 
combined in-network and out-of-network annual medical deductible of $100. This is the amount you have to 
pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid 
the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your 
deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay 
your share (your copayment or coinsurance amount) for the rest of the plan year. Additionally, you must pay a 
$25 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office.  
 
You have been asked to pay $125 ($100 + $25) for the specialist office visit provided. This amount includes a 
$100 deductible as you had not previously met the required annual deductible. Additionally, this amount 
includes a $25 copayment for the office visit provided by a specialist. 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 adjust the 
cost share for the office visit (99215) provided on January 4, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on August 23, 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 that the denied procedure code is not supported by the medical records submitted. 
 
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 63085 is "Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach 
with decompression of spinal cord and/or nerve root(s); thoracic, single segment." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case supported by the medical records. Our reviewer found the enrollee was being treated for spinal 
stenosis of the thoracic region. She underwent an exploration of fusion, partial corpectomy of T9 with revision 
laminectomy T9-10 and extension of fusion to T4 with robotics on 8/23/21. The procedure notes the 
transpedicular approach was continued and a partial corpectomy with the removal of the remainder of the disc 
and material as well as any loose fragments within the disc space itself. Approximately 50% of the posterior 
vertebral body was removed. Therefore, the records to support that a vertebral corpectomy (vertebral body 
resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); 
thoracic, single segment (CPT 63085) was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on August 23, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on January 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the services were medically necessary. 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 had network providers 
available who could have provided the laboratory work in this appeal. 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 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on January 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 12, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. 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 inpatient hospital services provided on November 
12, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided by 
network facility from October 4, 2021, to October 5, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you are appealing the 
$65 copayment because you were admitted to the hospital. The Plan denied your request. The Plan says you 
have been asked to pay 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 $65 
copayment for each in-and out-of-network emergency room visit.   
You have been asked to pay a $65 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency care benefit category. The medical record shows you were admitted as an outpatient to 
observation care. 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 visit 
provided by network facility from October 4, 2021, to October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism, electric, any type (E0627) purchased 
provided on November 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the seat lift mechanism. You say that you found no one in Albuquerque, NM 
who could match these prices or services. 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 the seat lift mechanism, electric, any type (E0627) 
purchased provided on November 17, 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care to return to prior level 
of function. The Plan denied your request. The Plan says that records do not show the enrollee is able to 
actively participate in the intensive rehabilitation program, of more than 1 type of skilled therapy 3 or more 
hours per day at least 5 days a week. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for atrial fibrillation, 
congestive heart failure, and pulmonary edema. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428), 
ground mileage (A0425), and ambulance oxygen and oxygen supplies (A0422) provided on April 16, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation, ground mileage, and ambulance 
oxygen and oxygen supplies. You say that you would like to appeal these services. The Plan denied your 
request. The Plan says the denial of non-emergent ground ambulance transport was appropriate given the 
clinical scenario and the guidance presented. The Plan also says that the oxygen and oxygen supplies are 
considered incidental to the enrollee's total episode of care. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that there is no documentation that the ambulance 
transport on April 16, 2021 was medically reasonable and necessary for the patient. Our physician reviewer 
found there is no documentation that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this patient on this date of service. Our reviewer 
also found that there is no documentation that the patient needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport on April 16, 2021. 
 
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 non-emergency ambulance transportation, ground mileage, and ambulance 
oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
the non-emergency ambulance transportation (A0428), ground mileage (A0425), and ambulance oxygen and 
oxygen supplies (A0422) provided on April 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 maintenance physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee has greatly benefited from PT and 
needs PT. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition. Our reviewer found that the patient has had prior therapy and 
the documentation does not reveal that the patient requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. Our physician reviewer also found that the requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the patient's current condition or to 
prevent or slow further deterioration. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 maintenance physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have seen this out-of-network provider in 
the past. The Plan denied your request. The Plan says the services have been requested 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 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 
an office visit to be provided by an out-of-network (OON) provider.