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

 
We decided that the Plan does not have to pre-approve a trans nasal sphenopalatine block. 
 
You asked the Plan to pre-approve a trans nasal sphenopalatine block. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a trans nasal sphenopalatine block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of other headache syndrome. On December 9, 
2021, it is documented that the enrollee felt better after an occipital nerve block and trigger point injection. The 
neurological exam was unremarkable. On April 21, 2022, it is documented that the enrollee was not doing well, 
and that Indocin was no longer working. The enrollee has been diagnosed with occipital neuralgia on the right 
side, as well as severe right frontal headaches which have become refractory to treatment. There is insufficient 
evidence to support the effectiveness of trans nasal sphenopalatine block. Therefore, the enrollee does not meet 
criteria for the requested services.  
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 trans nasal sphenopalatine block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a trans nasal sphenopalatine block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the physician provided medically necessary services 
in good faith. The Plan denied your request. The Plan says the rendering provider is a non-participating 
provider. The Plan also says that there is no referring provider involved in these 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 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 October 1, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram coded 93000 and the cast supplies 
coded Q4022 provided on January 25, 2022. 
 
You asked the Plan to pay for the electrocardiogram and the cast supplies. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 93000 and Q4022 are not supported in the medical record. Specifically, code 93000 
has a status indicator of "M". This means that this code is not billable. Code Q4022 was billed on an outpatient 
hospital bill type. This code is not payable when submitted on an outpatient hospital bill type. This means these 
codes are not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
electrocardiogram and the cast supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for the electrocardiogram coded 93000 and the cast supplies coded Q4022 provided on January 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 12, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 
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 the services provided on January 12, 2022 by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
neck provided on March 8, 2022. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that the amount is three times what the 
estimate was from the provider. The Plan denied your request. The Plan says you have been charged 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 $275 
copayment for advanced imaging services at an outpatient hospital.  
 
 
 
 
 
 You have been asked to pay $275 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce 
the copayment for a computed tomography (CT) scan of the neck provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle brace with heel cup provided on February 22, 2022. 
 
You asked the Plan to pay for the ankle brace with heel cup. You say that Original Medicare would have paid 
for this. The Plan denied your request. The Plan says the records do not support payment for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is zero information in the medical records provided pertaining to any issues the 
patient had with his ankle.  There is no mention of any ankle issues and the sole diagnosis listed in the medical 
record is hypertension.  There is no documentation as to why these items were ordered. Therefore, we decided 
that the Plan does not have to pay for the ankle brace with heel cup provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on January 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the service provided to the enrollee 
was out of medical necessity and you would like the claim to be paid. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on 
January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve femtosecond laser cataract 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 there is little evidence to support that this is medically necessary over the usual care. 
 
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 the record indicates that the enrollee has macular degeneration in both eyes. There is insufficient 
literature to support the safety and efficacy of the requested service for the enrollee's condition. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 femtosecond laser cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2022 to 
February 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that it is the facility's obligation to get 
authorization. The Plan denied your request. The Plan says the enrollee was in a self-pay assisted living 
facility, so it is the provider's obligation to secure authorization for any non-plan care. 
 
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 
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 medical services provided on February 18, 
2022 to February 21, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on February 
17, 2022. 
 
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 the ambulance service must meet all program coverage criteria in order for payment to be made. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
 
 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 services. Our reviewer says that the 
services at issue in this case were not medically Our physician reviewer found that the documentation did not 
support that your condition was such that the time needed to transport a patient by ground, or the instability by 
ground, posed a threat to your survival, or seriously endangered your health. The documentation did not 
support that the transferring hospital did not have adequate facilities to provide the medical services needed by 
you. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction and comprehensive exam provided on October 
13, 2021. 
 
You asked the Plan to pay for the refraction and comprehensive exam. The Plan denied your request. The Plan 
says vision exams are not eligible under the Pick Your Perks benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
 
  We looked at the file and the Plan's rules. The Plan offers a benefit for vision services, and also offers a Pick 
Your Perks benefit for various other services. The Pick Your Perks benefit does not cover refractions and 
comprehensive exams. Based on this information, we decided that the Plan's rules for coverage of the refraction 
and comprehensive exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction and comprehensive exam provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on January 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that you are requesting reimbursement for the 
claim. You say you had no explanation or orientation about the procedure. 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 
psychotherapy visit. We found no exception that would require the Plan to pay for the psychotherapy visit. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy visit provided on January 13, 
2022, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will deteriorate and sent home then you will not 
be able to care for yourself and you are at risk of falling at home. The Plan denied your request. The Plan says 
the stay is not medically necessary based on IRF 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 based on the medical records provided there is no documentation that you require the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Records do not clarify 
that treatment at the skilled nursing facility level is not appropriate in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 based on the medical records provided there is no documentation that the enrollee 
requires the intensive rehabilitation therapy program provided in an IRF. Records do not clarify that treatment 
at the skilled nursing facility level is not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records 
provided 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 enrollees medical conditions are stable on outpatient medications with no issues that require a physicians evaluation three or 
more times per week. The enrollee does require physical therapy and occupational therapy services, but the 
medical records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy 
program. Provided records do not explain why the intensive inpatient rehabilitation therapy program is 
necessary and why therapy at a lower level of care is not appropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 3, 2019, to May 31, 2019. 
 
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 the provider has reported skilled services with the incorrect Resource Utilization Group (RUG) 
Health Insurance Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 were not supported by the medical records. Our reviewer found that the available documentation in 
the case file does not support total skilled therapy treatment minutes of at least 500 minutes across all 
disciplines, an ADL score of 6 - 10, or at least one therapy discipline treating the enrollee at least 5 distinct 
calendar days during the lookback period of 5/4/19 through 5/10/19. The records do not support total skilled 
therapy treatment minutes of at least 500 minutes across all disciplines, or at least one therapy discipline 
treating the enrollee at least 5 distinct calendar days during the lookback period of 5/18/19 to 5/24/19. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from May 3, 2019, to May 31, 
2019.