Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional observation services provided to the enrollee from 
September 14, 2021, to September 23, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says additional hours of observation are not covered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presented to the emergency department (ED) following a fall down the stairs and injured her 
shoulder. There is a one-year history of chronic aphasia. On examination, there are no focal neurologic deficits. 
There are mid-lumbar tenderness notes, but no shoulder tenderness. The x-rays revealed no fractures. The 
computed tomography (CT) scan of the head was negative for acute changes. There was concern from the family that she would not be able to be cared for at home. Based on the enrollee not requiring inpatient care 
and being stable enough for a lower level of care, such as home health or subacute rehabilitation center, there 
was no reason to have additional hours of observation services beyond 72 hours. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional observation services provided to the enrollee from September 14, 2021, to September 
23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 
87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided on September 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87486, 
87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 remains not supported. The place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a office, POS 11; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an Skilled Nursing Facility POS 31. Also, the laboratory results submitted indicate the specimen was 
collected on September 14, 2020 and received by the lab on September 15, 2021. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87634, 87640, and 87798) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 10, 2021, and  
June 11, 2021. 
 
You asked the Plan to pay for the physician's services. You say that your doctor said this physician is one of the 
few specialists performing temporal artery biopsies and there are no other available specialists in the area. The 
Plan denied your request. The Plan says except for emergency care, we cannot pay a provider who has opted 
out of or been excluded or precluded from the Medicare Program. If you receive care from a provider who is 
not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
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 
physician's services provided on June 10, 2021, and June 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the requested Orencia is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Avsola, Entyvio, Inflectra, Renflexis, or 
Simponi Aria first. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orencia. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the provided records did not 
clearly show evidence that the enrollee had tried and failed Avsola, Entyvio, Inflectra, Renflexis, or Simponi 
Aria. The provided notes did not clearly describe a contraindication to the above preferred agents which are 
indicated for her condition, and there was no suggestion that any of them would be less effective than the 
requested Orencia for her condition based on current comparative studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 20, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says there is no 
reimbursement for vision services with an out-of-network provider. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services when provided through the Plans vision care provider. 
 
We looked at the file and the Plan's rules. The file shows that the eye refraction was not provided by the Plans 
vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on October 20, 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 require skilled nursing 
services, the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide treatment. The enrollee does not require skilled nursing services. The documentation does 
not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for LTACH services. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483) 
provided on September 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 laboratory services. Our reviewer found the provided 
documentation did not include a formal lab order or requisition by treating physician or provide an explanation 
for need for detailed drug screening such as an abnormal or unexpected urine screening. Therefore, without 
sufficient support made for lab testing from September 16, 2021, it will be considered not medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483) provided on September 16, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the vertiflex  spacer device is experimental. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 14, 2021, to 
July 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the RAP was 
submitted outside of the CMS timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that Home Health Agencies (HHAs) must submit a 
request for anticipated payment within 5 calendar days after the start of care date for initial 30-day periods and 
within 5 calendar days after the from date for each subsequent 30-day period of care.  
 
 
 We looked at the file and Medicare rules. In this case, the request for anticipated payment was not submitted 
within the required time frame. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from June 14, 2021, to July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230, K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says the power scooter is for community use and is therefore non-
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (E1230, K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT 
code 70450-26-59) provided on August 4, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 CT scan. Our reviewer found documentation submitted 
was reviewed and does not meet criteria. Provider reported CPT 70450 with modifier 59, and CPT 70496 for 
same session. Since these procedures were performed during the same session, only CPT 70496., as CPT 70450 is a component of CPT 70496. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the CT scan, head or brain; without contrast material (CPT code 70450-26-59) provided on 
August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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 the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power mobility device (power scooter) provided on 
December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for power scooter. You say that this device gave you the ability to live as normal a 
life as possible. The Plan denied your request. The Plan says the denial of payment for this device is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 a power mobility device (power scooter) provided 
on December 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visits provided from August 20, 2021, through August 27, 
2021. 
 
You asked the Plan to pay for the office visits. You say that you are requesting reimbursement saying that you 
paid $90, and the Plan only reimbursed a certain amount. The Plan denied your request. The Plan says that the 
claim was processed accordingly with your 2021 EOC benefits. 
 
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 did not send their schedule of cost share; therefore, we do not know if 
the Plan applied the correct copayment. Therefore, we decided that the Plan has to pay for the office visits 
provided from August 20, 2021, through August 27, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound of the heart provided on 
October 27, 2021. 
 
You asked the Plan to waive the deductible for an ultrasound of the heart. You say that you thought if your 
insurance was accepted then the plans payment was considered payment in full. You also say you do not want 
to be responsible for $493.41. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $750 deductible which applies to radiological diagnostic services, 
including ultrasounds.  
 
The ultrasound of the heart you asked the Plan to waive the deductible for falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $750 deductible which applies to radiological diagnostic 
services, including ultrasounds. This cost sharing is a contractual obligation that had not been met at the time an ultrasound of the heart was received on October 27, 2021. Therefore, we decided that the Plan does not have 
to waive the deductible for an ultrasound of the heart provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted 
his quality of life. The Plan denied your request. The Plan says there is a lack of evidence to support the 
devices as safe and effective. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis lumbar region with neurogenic claudication. 
He presented with low back pain that continues with radicular distribution to the posterior aspect of the right 
lower extremity extending just past the knee. He reports the pain is worse with extended periods of standing, 
twisting, and bending. The pain has been ongoing for quite some time. An exam reveals antalgic gait. There is 
moderate to severe pain with range of motion maneuvers of the lumbar spine. Straight leg raise is positive 
bilaterally. However, current evidence based medical guideline and peer reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy.  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. There is no discussion indicating that a DEXA scan has demonstrated the 
lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the request for the interspinous device at L4-L5 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.