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

 
We decided that the Plan does not have to pay for the pathology services provided on May 23, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON pathology services. You say that you do not see the enrollee but simply 
receive a sample from the in-network doctor. You feel that this should not require separate authorization. The 
Plan denied your request. The Plan says these services were ordered by an OON provider who did not obtain 
authorization to treat the enrollee. As neither service was authorized, the denial of payment is correct. 
 
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 nor is the ordering provider. 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 pathology services 
provided on May 23, 2022, 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 life alert (E1399). 
 
You asked the Plan to pre-approve a life alert. You say that you are appealing the denial of the life alert device. 
The Plan denied your request. The Plan says this device would be considered a convenience item that is not 
primarily medical in nature and not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an orthopedic to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation. You say that you are appealing the denied service. The 
Plan denied your request. The Plan says the requested provider is an OON provider, and it was confirmed that 
there is an in-network provider available that can treat the enrollee that is within the enrollee's service area. 
Therefore, the authorization request for services to be provided by an OON provider is denied. 
 
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 consultation with an orthopedic to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 24, 2022, by an OON provider. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration as the claim has not 
been paid in full or under the terms of the contract for the service provided to the patient. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 x-ray provided on March 24, 2022, by an OON 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the requested Minuteman procedure 
is medically necessary. The Plan denied your request. The Plan says the requested Minuteman procedure 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 the Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not medically necessary. Our physician reviewer 
found the enrollee was being treated for intervertebral disc degeneration of the lumbar region. She presented 
with back and left leg pain. Her right groin pain has improved. Her left leg and foot continue tingling. She did 
not get relief from her axial back pain from Intracept. The exam reveals tenderness to palpation over the 
iliopsoas bursa. There is pain with palpation over the lumbar facet. Seated straight leg raising was positive on 
the left. However, current evidence-based medical guideline and peer-reviewed literature do not fully support 
the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. According to the FDA, The HA Minuteman G3-R MIS Fusion Plate is a 
posterior, non-pedicle supplemental fixation device, intended for use at a single level in the non-cervical spine 
(T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not 
intended for stand-alone use. In addition, fusion indications within guidelines/literature for (existing or 
potential intraoperative) instability have not been documented and/or met in this case. In addition, there are 
multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not 
been fully documented as having been excluded and/or ruled out. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Minuteman procedure at L4-5, in this case, is 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that this drug is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered 
under the enrollee's medical benefit. 
 
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 Hydrocodone-
Acetaminophen.  
 Benefits for Hydrocodone-Acetaminophen 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 pay for the initial hospital care (99223) provided on April 18, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The E/M services in question were provided on the same day as E/M 
services (99204) provided by the same provider. This means that only one E/M service is payable. As code 
99204 has already been processed and paid by the Plan, code 99223 is not payable in this case. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on May 31, 2022, by an OON 
provider. 
 
You asked the Plan to pay for pathology services. You say that you are requesting reconsideration to please 
reconsider paying for the claim. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 pathology services provided on May 31, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from April 1, 2022, through April 23, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the skilled nursing facility care provided. 
 
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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that the enrollee did not have documented skilled nursing or skilled therapy needs. Daily skilled 
services are not shown to have been required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs, as a practical matter, could have been 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from April 1, 2022, through April 23, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided on 
January 1, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the skilled nursing facility care provided. 
 
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 pay for the SNF care. Our reviewer says that the 
services provided were not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that there is no evidence that the enrollee required or received skilled services on January 1, 
2022. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided on January 1, 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. The plan denied your request. The Plan says an IRF is not 
medically necessary, and the enrollees needs can be met at an alternate level of care. The enrollee can safely 
receive the services they need in a skilled nursing facility. 
 
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 that while the enrollees medical problems are stable. And there are no complex nursing or rehabilitation needs. While medical record supports a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from May 2, 2022, through May 31, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the inpatient skilled nursing facility care provided. 
 
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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. 
Additionally, as a practical matter, the enrollee did not meet severity of illness or intensity of service criteria 
for 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from May 2, 2022, through 
May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the facilities responsibility to obtain 
prior authorization and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider 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 nursing facility care provided on April 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing (81479). 
 
You asked the Plan to pre-approve an Rx Match test. You say that this test will help choose the best medication 
for the enrollee. The Plan denied your request. The Plan says tests are usually medically needed when the test 
will help with improving health outcomes. There is no proof or not enough proof this test (with MTHFR) 
improves health outcomes. As a result, this test is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory testing have been met. The 
records show that the Plan has requested medical records from the provider twice for this appeal. No response 
was received or submission of supporting medical records were received. Therefore, we decided that the Plan 
does not have to pre-approve laboratory testing (81479).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than Intensity-modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
13, 2022, to March 14, 2022. 
 
You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment can be made for these 
services. The Plan denied your request. The Plan says Medicare criteria were not 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. The enrollee appeared to have reached a plateau in function. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, could, 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 pay for skilled nursing facility (SNF) care provided from February 13, 2022, to March 14, 2022.