Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom and prefabricated lumbar-sacral orthosis 
provided to the enrollee on October 27, 2021. 
 
You asked the Plan to pre-approve the item. You say that the durable medical equipment was medically 
necessary The Plan denied your request. The Plan says the records show the enrollee did not have an 
appropriate face to face encounter documented in the records to substantiate the need for these items. 
 
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 item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is a request for both a custom lumbar brace and a second prefabricated lumbar brace. The 
enrollee was seen at the time of this request last year to discuss her diabetes. The record did not show an 
examination of the back or diagnosis of instability or back pain to help support this request. There was no 
explanation as to why two braces were requested. There was no documented plan for surgery or other 
indication for bracing. Therefore, without sufficient support made for this request, the lumbar braces will be 
considered not medically 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 the item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom and prefabricated lumbar-sacral orthosis provided to the enrollee on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma you received on February 24, 2022. 
 
You asked the Plan to pay for the platelet rich plasma. You say that you had no way of knowing that this would 
not be covered.  You also claim that the document you signed was just a formality. The Plan denied your 
request. The Plan says platelet rich plasma is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that platelet rich plasma is not covered for any 
condition except in the confines of a clinical trial.  You were not in a clinical trial.  In addition, you signed a 
document called "Non-Covered Services Notice" that explicitly states that by signing this document, you do so 
"knowing that you will have to pay for the services yourself either because they are not covered by your 
insurer, because your insurance is provided by an insurer outside of the United States, or because you do not 
have insurance."  This means you were explicitly told that the platelet rich plasma would not be covered and 
you chose to proceed anyway. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the platelet rich plasma have not been met. Therefore, we decided that the Plan does not have to 
pay for platelet rich plasma you received on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab testing. You say that the enrollee is in an active treatment plan with 
the provider who recently joined the OON group. It is felt that this should be approved for continuity of care. 
The Plan denied your request. The Plan says this lab testing is not shown to be emergent/urgently needed. No 
authorization to continue with the OON provider was submitted by the date in question. Lab testing is available 
from network providers. 
 
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 lab testing provided on April 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure fills a treatment gap for those 
patients that do not receive adequate relief from traditional conservative methods and don't have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says that this service is 
considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental for back pain. More research is needed. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment based on medical necessity. The Plan denied your request. The Plan says prior 
authorization was not obtained for these services rendered by an OON 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group. You also say the rendering physician depends upon the hospital staff to 
verify eligibility and to obtain the proper authorization from the patient's insurance company. The Plan denied 
your request. The Plan says services from non-participating providers are not covered under this plan unless 
preauthorized. 
 
 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 subsequent nursing facility care provided on 
February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be provided additional 
reimbursement. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on 
February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the Plan should pay for these 
services. The Plan denied your request. The Plan says the services are not covered because they were rendered 
with an out-of-network provider and 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 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 subsequent nursing facility care (99308) provided 
on February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under open access unless preauthorized. 
 
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 March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were ordered by a physician and are 
supported in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place 
of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with POS code 11 for 
samples taken in an office setting. However, the records indicate that this sample was collected by a house call 
physicians group and the specimen was collected in the enrollees home or residential facility. Therefore, we 
decided that the Plan does not have to pay for lab services provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest wall oscillation device.  
You asked the Plan to pre-approve high-frequency chest wall oscillation device. You say that the enrollee is 
having difficulty breathing and choking on mucus. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for this device. 
 
The Plan follows Medicare rules. Medicare rules state that high-frequency chest wall oscillation devices are 
only covered under certain indications. 
 
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 high-frequency chest wall oscillation 
device. Our reviewer says that the enrollee does not meet the Medicare criteria for a high-frequency chest wall 
oscillation device. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease. The 
record does not indicate the presence of bronchiectasis. The record does not indicate that the enrollee has one 
of the covered conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high-frequency chest wall oscillation device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high-frequency chest wall oscillation device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for remote monitoring services provided from 
June 2, 2020, through April 23, 2022. 
 
You asked the Plan to waive the copayments for remote monitoring services. You say that the services are 
unauthorized and unneeded. The Plan denied your request. The Plan says the $45 copayment applied correctly 
to the remote monitoring services in the 2020 and 2021 Plan year. The Plan also says the 2022 claims 
reprocessed to only apply a $43 copayment. 
 
  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 $45 
copayment for visits to in-network specialists in the 2020 and 2021 Plan year and a $43 copayment for visits to 
in-network specialists in the 2022 Plan year.  
 
There is a $45 copayment for remote monitoring services in the 2020 and 2021 Plan year. There is a $43 
copayment for remote monitoring services in the 2022 Plan year. You have been asked to pay less the standard 
copayment for some dates of service due to the allowed amount being less than the standard copayment. The 
remote monitoring services fall within the Physician/Practitioner Services, Including Doctors Office Visits 
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 copayments for remote monitoring services 
provided from June 2, 2020, through April 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for services provided by a Certified Registered Nurse Anesthetist (CRNA) 
on December 14, 2021. 
 
You asked the Plan to pay for the CRNA services. You say that the provider of service is a CRNA, so this 
should be paid. The Plan denied your request. The Plan says that this provider is set up in their system as a 
Registered Nurse, not a CRNA. 
 
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's sole rationale for denial is that the provider of service is 
not set up as a CRNA.  However, you have provided screen prints from the Centers for Medicare and Medicaid 
Services National Provider Identification database that explicitly states that this provider is registered as a 
CRNA.  The Plan has failed to provide any evidence disputing this. The burden is on the Plan to show that its 
denial is correct, and it has failed to do so here. Therefore, we decided that the Plan has to pay for services 
provided by a Certified Registered Nurse Anesthetist (CRNA) on December 14, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 49505 billed on March 7, 2022. 
 
You asked the Plan to pay for procedure code 49505. You say that you are resubmitting the claim with medical 
records and the claim should be reviewed for payment. The Plan denied your request. The Plan says that 
procedure code 49505 has an MUE value of 1 but 2 units were billed. 
 
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. The Plan says procedure code 49505 was billed twice. The claim form and 
Remittance Advice submitted supports only one unit of this procedure code being billed. The Plan has not 
forwarded any other evidence or rationale to support their denial of this code. It is the burden of the Health Plan 
to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for procedure code 49505 billed on March 7, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Marriage and Family Therapist (LMFT) from February 8, 2022, to March 7, 2022. 
 
You asked the Plan to pay for the LMFT services. You say that this is the only therapist who has helped you. 
The Plan denied your request. The Plan says you saw an ineligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. You saw a LMFT.  This 
is not an eligible provider type for Medicare. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the LMFT services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Marriage and Family Therapist (LMFT) from February 8, 2022, to March 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs rehabilitation and is 
unable to care for themselves. The Plan denied your request. The Plan says the enrollee's condition does not 
meet the requirements for coverage of skilled nursing facility services per Chapter 8 of the Medicare Benefit 
Policy Manual. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that the 83 year old enrollee with a past medical history of autism spectrum disorder and varicose veins who 
presented to the acute hospital on August 14, 2022 with recurrent falls and failure to thrive. The enrollee was 
treated in the hospital with a back brace for vertebral compression fractures, potassium replacement for 
hypokalemia and monitoring for an intracranial hemorrhage and condition has stabilized. The enrollee is weak 
and deconditioned with confusion and is working with speech, physical and occupational therapy. The enrollee 
is walking 450 feet with supervision and no assistive device and is supervision level for transfers and is 
moderate to maximum assist with some activities of daily living (dressing, toileting, bathing). The enrollee 
otherwise is reported to be medically stable for discharge on outpatient medications. Our physician reviewer 
found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.