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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308, 99309) chronic 
care management (99490) and advanced care planning (99498) provided on October 12, 2021 to November 10, 
2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the nursing facility care. You say that say the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 Plan must follow Medicare rules. Medicare rules say that 
providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
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 subsequent nursing facility care (99308, 
99309) chronic care management (99490) and advanced care planning (99498) provided on October 12, 2021 
to November 10, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with power tilt 
seating system. 
 
You asked the Plan to pre-approve the PWC. You say that it is felt that this PWC is necessary as the enrollee's 
condition has worsened. The Plan denied your request. The Plan says it appears that the loss of function as due 
to a flare up in the enrollee's condition. This has since been treated. Even during the flare up, the enrollee was 
able to ambulate enough to perform MRADLs in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 PWC. Our reviewer says that the 
documentation does not support that a PWC is medically necessary for the enrollee. Our physician reviewer 
found the enrollee is a 76-year-old female with a past medical history of polymyositis. Records document she is walking 50 feet with a wheeled walker with contact guard assistance and is contact guard assist for 
transfers. There is not sufficient evidence to show she is unable to perform MRADLs within a reasonable time 
frame to justify a PWC. 
 
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 PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 3 power wheelchair (PWC) with power tilt seating system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cytogenic laboratory testing. 
 
You asked the Plan to pre-approve cytogenic study. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this 
test is experimental for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules state that cytogenic studies are only covered when reasonable 
and necessary for the diagnosis or treatment of certain conditions. 
 
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 cytogenic study. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested cytogenic study. Our physician reviewer 
found cytogenics on peripheral blood for the work-up of monoclonal gammopathy or normocytic 
normochromic anemia is not a standard of care. There is no clear indication mentioned or rationale for 
utilization of this test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cytogenic study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cytogenic laboratory testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with routine labs, x-rays, and procedures to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visits with routine labs, x-rays, and procedures. You say that the 
in-network facility is not equipped to support the operation. You say you are recommending the out-of-network 
facility to provide continuity of care given the enrollee's complex medical issues. The Plan denied your request. 
The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits with routine labs, x-rays, and procedures to be provided by an out-of-network (OON) provider.
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 you cannot walk and your hemoglobin is low. The 
Plan denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
29, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 29, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dronabinol.  
 
 
 
  
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee needs to see a vasculitis specialist. 
You say getting an opinion from the specialist will be very helpful in guiding further work up and management 
for this enrollee. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The records provided for review do not show that the service at 
issue was urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan. You say that you do not want to see an in-network provider and 
would like to see another provider. The Plan denied your request. The Plan says an in-network provider was 
offered to the enrollee that provides the same quality of service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on 
July 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services provided were medically necessary. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 individual psychotherapy services (90832) 
provided on July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 21, 
2021. 
 
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 benefits were coordinated. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer.  Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has coordinated 
benefits with the enrollee, provider, and other insurance. The plan has confirmed that the claim was submitted 
to the primary insurance, and is being processed currently.. As the secondary insurer, the Plan cannot be held 
responsible for the services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 21, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 85025) provided 
on October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the labs were medically necessary. The Plan 
denied your request. The Plan says services were provided by an out-of-network provider without prior 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers.  
 The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 85025) 
provided on October 19, 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 procedure code 70450 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on July 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like reconsideration based on the medical 
records provided. The Plan denied your request. The Plan says the services were provided out-of-network 
without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on July 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a septoplasty. 
 
You asked the Plan to pre-approve a septoplasty. You say that the requested septoplasty is medically necessary. 
The Plan denied your request. The Plan says that the requested septoplasty is not medically necessary. 
 
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 a septoplasty. Our reviewer says that 
the requested septoplasty is medically necessary. Our physician reviewer found based on available clinical 
documentation, the requested services for septoplasty meet criteria for being medically necessary and 
reasonable. Clinical documentation included description of deviated nasal septum with septal ulceration. A 
multicenter randomized controlled trial demonstrated that septoplasty with or without turbinoplasty was more 
effective than nonsurgical management for nasal obstruction in adults with a deviated nasal septum (van 
Egmond et al., Lancet 2019). In summary, the requested septoplasty meets criteria for being medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Please note, the Plan reviewed Local 
Coverage Determination (LCD) L39051 to support their denial. This LCD is not in the correct jurisdiction and 
is not binding in this case. We based our review on Medicare's medical necessity criteria. Based on this 
information, we decided that Medicare rules for coverage of a septoplasty have been met. Therefore, we 
decided that the Plan has to pre-approve a septoplasty.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity other than joint (73718) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) of the lower extremity other than 
joint. You say that a magnetic resonance imaging (MRI) is needed to assess for other etiologies of persistent 
pain and swelling that has not responded to non-steroidal anti-inflammatory drugs (NSAIDs) and steroids. The 
Plan denied your request. The Plan says this provider is a non-participating provider in the Plan's network. The 
Plan also says that the enrollee could receive this service from an in-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging (MRI) of the lower extremity other than joint (73718) to be provided by an out-
of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychology consultation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the psychology consultation. You say that this out-of-network provider 
gives amazing advice and is interactive. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The records provided for review do not show that the service at 
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the psychology 
consultation to be provided by an out-of-network (OON) provider.