Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 18, 2021. 
 
You asked the Plan to pay for the medical services. You say that you had to seek care from this provider 
because your symptoms were not being resolved. The Plan denied your request. The Plan says this provider has 
opted out of Medicare, so any services provided by him cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical 
services provided on October 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you believe this service 
should apply to your maximum out-of-pocket. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 only in-network 
services apply to your in-network maximum out-of-pocket. Your contract with the Plan also clearly says that 
you must pay a $250 copayment for each ambulance trip. You had one (1) out-of-network ambulance trip. The 
Plan charged you $250 for these services. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech therapy services provided on January 5, 2021, and 
January 11, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim lists a place of service as an office setting. The medical records 
show that the enrollee received services virtually in her home. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the speech therapy services provided on January 5, 2021, and January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that there is evidence to support that this 
treatment would be beneficial for this enrollee. The Plan denied your request. The Plan says this is an 
experimental procedure at this time. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a female with chronic low back pain. She has multi-level degenerative 
disc disease, has had laminectomy procedures, and has a spinal cord stimulator in place. The request is for the 
Intracept procedure at L3 and L4.  
 
This is considered an experimental/ investigational procedure. Therefore, the request is deemed not medically 
reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on February 11, 
2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that an office visit should be the same as 
a specialist office visit and not vision diagnostic. The Plan denied your request. The Plan says you have been 
charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for a Medicare-covered visit.  
 
You have been asked to pay a $50 copayment for an eye exam. The eye exam falls within the Vision 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 an eye exam provided on 
February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an oxygen concentrator provided on 
January 18, 2022. 
 
You asked the Plan to waive the deductible for an oxygen concentrator. You say that the doctor gave you a 
prescription and this item has been covered on previous claims. You say that you would like your cost share to 
be reconsidered to 20%. The Plan denied your request. The Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to durable medical equipment.  
 
 
 
 
 
  
The item or service you asked the Plan to waive the deductible for falls within the Durable Medical 
Equipment (DME) and related supplies benefit category. The plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible which applies to durable medical equipment. This cost 
sharing is a contractual obligation that had not been met at the time an oxygen concentrator was received on 
January 18, 2022. The allowed amount of this claim is $108.21, so you are responsible for a deductible amount 
of $108.21. Therefore, we decided that the Plan does not have to waive the deductible for an oxygen 
concentrator provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Implantable Loop Recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that an Implantable loop recorder is not medically necessary at this 
time. 
 
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. A non-invasive, 30 
day ambulatory ECG recorder has not been performed in the workup of this patient to assess for possible atrial 
fibrillation. As such, guidelines would not support ILR implantation at this time. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in this patients clinical management. 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 an Implantable Loop Recorder (ILR) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Neurology specialist services provided on November 22, 
2021 to November 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Neurology specialist services. You say that I am appealing this because it is 
unfair as these are services that wouldve been covered if I was at home The Plan denied your request. The 
Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Neurology specialist services provided on 
November 22, 2021 to November 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vision care office visit provided on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for the vision care office visit. You say that you were allowed one 
exam a year and you should not have to pay. You say that you would like to be reimbursed. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 the Plan covers outpatient 
physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for 
age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for 
eyeglasses/contacts. 
 
The eye refraction that you asked the Plan to pay for is considered a routine vision service. This service is not 
covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
a vision care office visit provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraspinal chiropractic manipulative treatment 
represented by code 98943. 
 
You asked the Plan to pre-approve the extraspinal chiropractic care. You say that the requested chiropractic 
treatments will reduce or eliminate your pain, improve your range of motion and overall functionality. The Plan 
denied your request. The Plan says the type of chiropractic care being requested is not covered by Medicare or 
under your contract. 
 
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 service at issue is not manual manipulation of the spine. Rather, the code being 
requested is for chiropractic treatment of an extraspinal (outside of the spine) region. Therefore, we decided 
that the Plan does not have to pre-approve extraspinal chiropractic manipulative treatment represented by code 
98943.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for a specialist office visit provided on November 1, 
2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that you did not see this provider. You 
say that you saw a provider that was in-network. The Plan denied your request. The Plan says that the correct 
amount was applied to your deductible. 
 
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 indicated they have requested a corrected claim from 
the providers office. To date, this information has not been received and forwarded by the Plan. Therefore, we 
decided that the Plan has to waive the deductible for a specialist office visit provided on November 1, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the BRCA1 and BRCA2 gene analysis testing. 
 
You asked the Plan to pre-approve the BRCA1 and BRCA2 gene analysis testing. You say that you would like 
reconsideration because this testing is appropriate and necessary to determine future treatment protocols and 
best outcomes based on the current diagnosis of extra-ovarian papillary serous adenocarcinoma. The Plan 
denied your request. The Plan says that the enrollee has had previous testing of the same genes. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the BRCA1 and BRCA2 gene analysis 
testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found an individuals personal and/or family history may be explained by 
more than one inherited cancer syndrome; thus, phenotype-directed testing based on personal and family 
history through a multi-gene panel test may be more efficient and cost-effective and increase the yield of 
detecting a pathogenic/likely pathogenic variant in a gene that will impact medical management for the 
individual or his/her at-risk family members. Panel genetic testing is now considered a standard of care in 
patients at high risk to carry a genetic mutation. Finding mutation can effect surveillance and treatment options 
as well as indications to test family members. This enrollee has breast cancer and an ovarian cancer syndrome 
and updated testing occurred since she was tested for BRCA1 and 2 back in 2008. 
 
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 BRCA1 and BRCA2 gene analysis testing have been met. Therefore, we 
decided that the Plan has to pre-approve the BRCA1 and BRCA2 gene analysis testing.  
 
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 medical services provided on October 5, 2021. 
 
You asked the Plan to pay for the medical services. You say that you had to seek care from this provider 
because your symptoms were not being resolved. The Plan denied your request. The Plan says this provider has 
opted out of Medicare, so any services provided by him cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical 
services provided on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on September 23, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that the service provided does not need an 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON providers and there was no 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 specialist office visit provided on September 
23, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport provided on December 
23, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transport. You say that the patient was discharged 
from the hospital and transported to a skilled nursing facility following treatment for altered mental status and 
delirium. He required medical supervision during transport. The Plan denied your request. The Plan says non-
emergent ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergency ambulance transport. 
Our reviewer says that criteria for non-emergency ambulance are not met in this case. Our physician reviewer 
found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for this patient. The cited reason for ambulance 
transport was a need for cot transport due to delirium and acute kidney injury. He was stable at the time of 
hospital discharge. A stretcher van would have been medically appropriate. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transport provided on December 23, 
2021.