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

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says the request for L4 and L5 medical 
branch blocks is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no physical examination documented which evaluates range of motion limitations, facet 
maneuvers, or referred pain pattern. An MRI of the lumbar spine was reviewed showing an intact L4-L5 fusion 
and moderate central canal stenosis at L3-L4. The enrollee had bilateral L3-L4 transforaminal epidural steroid 
injections (TFESI) but there is no documentation of the degree and duration of pain relief achieved. There is a 
lack of documentation that addresses whether the enrollee's lumbar radiculopathy has been successfully treated. 
There is a lack of a physical exam which documents facet joint dysfunction. Therefore, at this point, the request 
is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 28, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
that this claim was wrongfully denied and needs to be changed. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
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 September 28, 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 the ambulance response and treatment with no 
transport provided on September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve a GI tract imaging. The Plan denied your request. The Plan says this request 
is not medically necessary because the records do not show that the enrollee has been evaluated with an 
esophagogastroduodenoscopy (EGD), colonoscopy, or enteroscopy. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 GI tract imaging. Our reviewer says 
that the enrollee does not meet the coverage criteria for a GI tract imaging. Our physician reviewer found the 
available records state the enrollee has iron deficiency anemia. However, no laboratory evidence of iron 
deficiency nor anemia was provided. Our reviewer also found that the available records do not support that the 
enrollee has recently undergone a complete colonoscopy nor recent EGD. 
 
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 GI tract imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a gastrointestinal (GI) tract imaging (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), 
manual therapy (97140), electrical stimulation (G0283), and the hot or cold packs therapy (97010) provided on 
October 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), manual 
therapy (97140), electrical stimulation (G0283), and the hot or cold packs therapy (97010) provided on  
October 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the most appropriate level 
of care to meet the enrollee's needs. You say that the enrollee is stable for transfer. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and the enrollee can receive the care 
they need in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care setting. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 7, 
2022, to August 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 days 1-7 and a $0 copayment per day for days 8-90 for inpatient hospital care.  
 
You have been asked to pay a $295 copayment per day for days 1-7 and a $0 copayment per day for days 8-90 
for inpatient hospital care. The total amount you are being asked to pay is $2,360 ($295 x 8 days = $2,360). 
You were being charged for two separate inpatient stays. This item/service falls within the inpatient hospital 
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 inpatient hospital care provided 
on April 7, 2022, to August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the Plan's denial. 
The Plan denied your request. The Plan says there is no documentation that you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. 
 
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 SSBCI benefits. Our reviewer says that 
you do not meet the coverage criteria for SSBCI benefits. Our physician reviewer found the criteria for this 
benefit includes the patient requiring intensive care management (2 hospital admissions or 3 emergency room 
visits in last 60 days), be at high risk for hospitalization, and with an active complex condition that is life 
threatening or significantly limiting the health or function of the patient. However, you do not meet these 
criteria, as you do not require intensive care management, and you do not have a life-threatening condition with 
risk of hospitalization based on the provided documentation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient psychiatric hospitalization provided on November 1, 2022, to 
November 4, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that an inpatient admission was 
medically necessary. The Plan denied your request. The Plan says that the medical criteria for an inpatient 
psychiatric hospitalization were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that an inpatient psychiatric admission and hospitalization was medically necessary. Our 
physician reviewer found this enrollee did appear to require inpatient mental health treatment as he was a 
danger to himself but not others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric hospitalization provided on November 1, 2022, to November 
4, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home physical therapy visits from 
February 24, 2023, to March 18, 2023. 
 
You asked the Plan to pre-approve home health services. You say that you need additional physical therapy. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not show any acute functional status change and the enrollee has completed home exercise 
plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home physical therapy visits from February 24, 2023, to March 
18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4154 x 642). 
 
You asked the Plan to pre-approve enteral formula. You say that you need this nutritional supplementation. 
You say that you were approved for it previously. You also say that you do not understand why it is being 
denied now. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral formula (B4154 x 642).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on December 1, 2022. 
 You asked the Plan to pay for the refraction. You say that the refraction is a covered service as a part of your 
routine eye exam. You say you confirmed with the Plan that the provider was in-network. The Plan denied your 
request. The Plan says the refraction is not a covered 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. The Plan covers the refraction during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed as a part of a routine 
eye exam. The medical record shows diagnoses for cataracts and myopia which makes the exam medical in 
nature. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on December 1, 2022.  
 
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on May 11, 2022, to July 05, 
2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient hospital stay 
provided on May 11, 2022, to July 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and periodontal 
maintenance (D4910), provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not exhausted these services. 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 D4910 was exhausted on date of service February 14, 2022, and D0120 was exhausted 
on date of service January 11, 2022, and February 14, 2022. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), and periodontal maintenance (D4910), provided on April 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liquid oxygen. 
 
You asked the Plan to pre-approve liquid oxygen. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items that are not medically necessary arew 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 liquid oxygen. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the medical records do not document that 
oxygen via an alternative delivery means such as a concentrator would not meet the patient's medical needs and 
improve the patient's condition in the home setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liquid oxygen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve liquid oxygen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a walker, folding, wheeled, adjustable or fixed 
height (E0143) and sales tax (S9999) provided on September 6, 2022. 
 
You asked the Plan to reimburse you for a walker and sales tax. You say that you disagree with the charges and 
are requesting a full refund for the walker. The Plan denied your request. The Plan says this cost sharing was 
charged 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 10% 
coinsurance for DME and related supplies. Your contract with the Plan also clearly says that sales tax is not 
medical in nature and will never be covered with your Plan. 
 
 
 
 You have been asked to pay a 10% coinsurance for a walker and sales tax in the amount of $16.27. The records 
show that you billed the Plan in the amount of $209.99 and the allowed amount is $67.68. The records also 
show that you are responsible for a coinsurance of 10% and you were assessed a coinsurance of $6.76 ($67.68 
x 10% = $6.76). Medicare rules say that sales tax is not a covered benefit, therefore, you are responsible for the 
sales tax charge. 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 reimburse you for a walker, folding, wheeled, adjustable 
or fixed height (E0143) and sales tax (S9999) provided on September 6, 2022.
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 you went home following surgery and fell so you 
need this rehabilitation. The Plan denied your request. The Plan says your records do not show that you need an 
intensive team for your care, the services needed can be provided safely in other settings, a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 intensive rehabilitation, you have standard post-acute 
rehabilitation and skilled nursing needs that can reasonably be managed at a lower level of care without 
admission to an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92250 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 92250. You say that these services should be paid. The Plan 
denied your request. The Plan says payment for code 92250 is bundled into payment for code 92133.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 92250 
is a column II code to column I code 92133. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 92250 billed for date of service October 13, 
2022.