Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 23, 2022, to 
January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 23, 2022. The NOA was not received by the Plan until November 
24, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from January 23, 2022, to January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered 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 Oxycodone.  
 
Benefits for Oxycodone 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy (PT) services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-
emergent and can be provided 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 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 physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive medication services provided on  
March 9, 2022. 
 
You asked the Plan to pay for comprehensive medication services. You say that the comprehensive medication 
services should be covered as denial of coverage would be detrimental to your health. The Plan denied your 
request. The Plan says these services require prior authorization. Medical records still have not been able to be 
obtained to determine financial liability or medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 comprehensive medication services 
have been met. The Plan has not been able to obtain the medical records. Therefore, we decided that the Plan 
does not have to pay for comprehensive medication services provided on March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) 
provided on May 29, 2022. 
 
You asked the Plan to pay for ambulance response without transport. You say that these services were 
necessary and should be covered. The Plan denied your request. The Plan says the ambulance benefit is a 
transportation benefit; when no transportation is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport (A0998) provided on May 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on July 20, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says that based on Medicare guidelines, place of 
service of 31 does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported its denial rationale as they have not 
provided evidence that shows that the place of service code 31 is not appropriate. Therefore, we decided that 
the Plan has to pay for physician's services provided on July 20, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LUCI smart sensor system (K0108) and repair or 
service of medical equipment by a trained technician; requested for labor to install the LUCI system (K0739). 
 
You asked the Plan to pre-approve a LUCI smart sensor system repair or service of medical equipment by a 
trained technician; requested for labor to install the LUCI system. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that for the purposes of Medicare reimbursement, repairs 
are not synonymous with replacements. 
 
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 LUCI smart sensor system repair or service of medical equipment by a trained technician; requested for labor to install the LUCI system. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you need the 
wheelchair in the home. Medicare covers for service in the home not the community. It is unclear he requires 
the device for use in the home. 
 
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 LUCI smart sensor system repair or service of medical equipment by a trained 
technician; requested for labor to install the LUCI system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a LUCI smart sensor system (K0108) and repair or service of medical 
equipment by a trained technician; requested for labor to install the LUCI system (K0739).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on August 
29, 2021, and August 30, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 309. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the provided documentation did not clearly show evidence of ACS or specific findings of atherosclerosis 
of the bypass graft of this patient to support I25.810 (Atherosclerosis of coronary artery bypass graft(s) without 
angina pectoris) as an appropriate diagnosis code in this case. Also, there was insufficient support found in the 
documentation for complexity or severity of the case to deserve DRG 309 (CARDIAC ARRHYTHMIA AND 
CONDUCTION DISORDERS WITH CC).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on August 29, 2021, and August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression (low back surgery). 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the surgery locations requested do not match the surgery locations recommended in the 
medical notes. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The documentation indicated physical therapy was in 
2019 and that the epidural injections were in 2017 and 2019. Recent conservative care should typically be 
trialed before surgical procedures. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar decompression (low back surgery).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on April 21, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 28, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the Plan 
requires prior authorization for coverage of an out-of-network provider. The Plan allows for out-of-network 
coverage for emergency 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 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 June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104) for 
tooth number 13, gum surgery (D4266) for tooth number 13, implant placement (D6010) for tooth number 13, 
and a prefabricated abutment (D6056) for tooth number 13. 
 
You asked the Plan to pre-approve a bone graft at time of implant placement (D6104) for tooth number 13, 
gum surgery (D4266) for tooth number 13, implant placement (D6010) for tooth number 13, and a 
prefabricated abutment (D6056) for tooth number 13. You say that this is medically necessary. You also say 
your provider advised this is the only thing you can have done. The Plan denied your request. The Plan says 
your EOC lists the covered codes and limitations. The Plan also says that the requested codes/services are not 
listed, and are therefore excluded from coverage. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft at time of implant placement (D6104) for tooth number 13, gum surgery (D4266) for tooth number 
13, implant placement (D6010) for tooth number 13, and a prefabricated abutment (D6056) for tooth number 
13.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on June 23, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says that payment cannot be made as the 
enrollee has decided to not seek further cancer treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment stating that the evidence indicates the 
enrollee has declined further treatment for their cancer. However, no evidence of this was provided in the case 
file submitted. It does not appear that the Plan made a reasonable and diligent effort to gather medical records 
that would support the enrollee declining further cancer treatment.  Therefore, we decided that the Plan has to 
pay for the genetic testing services provided on June 23, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4266) tooth #4 and tooth #7, implant 
placement (D6010) tooth #4, prefabricated abutment (D6056) tooth #4, bone graft at time of implant placement 
(D6104) tooth #4, implant/abutment supported fixed denture edentulous upper arch (D6114) tooth #10 and 
collection and application of blood collected from the patient (D7921). 
 
You asked the Plan to pre-approve dental services. You say that your provider says you need the requested 
services, your current bridge is causing infection. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 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. Gum surgery (D4266), 
implant placement (D6010), prefabricated abutment (D6056), bone graft at time of implant placement (D6104), 
implant/abutment supported fixed denture edentulous upper arch (D6114) and collection and application of 
blood collected from the patient (D7921) are not covered under the Plans dental benefits. 
 
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 pre-approve gum 
surgery (D4266) tooth #4 and tooth #7, implant placement (D6010) tooth #4, prefabricated abutment (D6056) 
tooth #4, bone graft at time of implant placement (D6104) tooth #4, implant/abutment supported fixed denture 
edentulous upper arch (D6114) tooth #10 and collection and application of blood collected from the patient 
(D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests, platform systems, and foot kit.  
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medicaly 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 the items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation doesn't support the medical necessity for the requested accessories. The approved 
wheelchair already has amputee stump supports and a pressure-relieving cushion. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve elevating leg rests, platform systems, and foot kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia Clickjet. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Orencia Clickjet.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 home visit provided on May 9, 2022, by an 
out-of-network (OON) provider.