Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered. 
 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 psychotherapy provided on February 17, 2023, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory assist device provided on January 18, 2023. 
 
You asked the Plan to pay for respiratory assist device. You say that you were told by customer service that the 
device would be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for respiratory assist device 
provided on January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on August 19, 2022. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you disagree 
with the copayment applied. The Plan denied your request. The Plan says this cost sharing was charged 
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 you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for each emergency room (ER) visit. This item/service falls 
within the emergency 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 each 
emergency room (ER) visit provided on August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 You asked the Plan to pre-approve the home ventilator. You say that the submitted documentation provides the 
medical necessity of the ventilator.  The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for the enrollee because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS). 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the provided source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of such a 
device has not been documented. The Plan has indicated coverage for such a device is available upon request. 
The elements of the coverage criteria are not satisfied. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on April 4, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you were 
not aware a cost share would be applied. The Plan denied your request. The Plan says this cost sharing was 
charged 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 you must pay a $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on April 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF 
admission. 
 
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 admission. Our reviewer says that 
the requested SNF admission is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor system (CGM) (A9277) 
and sensor (A9276). 
 
You asked the Plan to pre-approve the CGM and sensor. You say that the enrollee suffers from complicated 
uncontrolled diabetes mellitus type 2 and is on insulin and two oral diabetic medications. You also say that the 
FreeStyle Libre 2 will benefit the enrollee to better control her diabetes. The Plan denied your request. The 
Plan says this benefit is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that products reviewed by the PDAC which do not 
meet the DME benefit category requirements must be coded as A9276, A9277, A9278, or A9279 and will be 
denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CGM (A9277) and sensor (A9276) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor system (CGM) (A9277) and sensor (A9276).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not enough proof that shows this procedure is as safe and as 
effective as other standard treatment options 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 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 procedure (64628).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and could not get up due to extreme pain so you called 911 to ask where to go for care. The ambulance crew 
checked you over but could not transport you to the nearest medical center because it was out of their services 
area. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at the time of an implant (D6104), an 
endosteal implant (D6010), and a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve D6104, D6010, and D4266. You say that you need this dental work. The 
Plan denied your request. The Plan says these services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft at the time of an implant (D6104), an endosteal implant (D6010), and a guided tissue regeneration 
(D4266).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from March 13, 2023, to April 11, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the continued SNF care should be paid for 
under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for 
continued SNF care. 
 
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 continued SNF care. Our reviewer says 
that the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee did not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued skilled nursing facility (SNF) care provided from March 13, 2023, to 
April 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial psychiatric hospitalization.  
 
You asked the Plan to pre-approve partial psychiatric hospitalization. You say that partial psychiatric 
hospitalization is medically necessary. The Plan denied your request. The Plan says partial psychiatric 
hospitalization is not medically necessary. The Plan says based on the information provided, the patient can be 
safely managed on an outpatient basis by beginning visits with a psychiatrist to initiate/optimize 
pharmacotherapy. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 partial psychiatric hospitalization. Our 
reviewer says that the requested partial psychiatric hospitalization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that based upon review of the records provided, this 
enrollee was not showing any dangerousness to self or others and has not been exhibiting severe psychological 
or psychiatric impairment requiring this level of care. The enrollee was not showing any perceptual 
disturbance, psychosis or aggressive behaviors. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the partial hospitalization level of care rather than a lower level of care as the 
enrollee did not have any suicidal or homicidal thoughts or behavioral disturbance and her symptomatology 
could be treated at a lower level of care. This enrollee did not appear to require partial hospitalization 
treatment. The enrollee was not showing any severity of psychological or psychiatric illness. Based upon 
review the records provided this enrollee does not meet the criteria for treatment at partial hospitalization level 
of care and could have been treated in a lesser restrictive setting as she was not showing any suicidal or 
homicidal ideation and was not showing any psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial psychiatric hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve partial psychiatric hospitalization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on June 10, 2022. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this device is contraindicated for the enrollee, and 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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #14 
provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that your coverage had 
changed, and you would like the Plan to cover the dental services at the 2023 rate. The Plan denied your 
request. The Plan says the denial of payment for these services is correct because the crown and core buildup 
are not covered by the Plan. Also, it was verified that you received the 2022 Annual Notice of Change (ANOC) 
on September 29, 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) and core buildup (D2950) for tooth #14 provided on November 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that the lack of medical 
care was dangerous and you do not feel the enrollee should be liable for the cost share. The Plan denied your 
request. The Plan says this cost sharing was charged 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 you must pay a $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 
emergency room (ER) visit provided on March 11, 2023.