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

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on January 1, 2023. 
 
 You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the duty 
nurse determined that you should go to the hospital. You also say that this was out of your hands. The Plan 
denied your request. The Plan says this service is not covered under your plan. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition.  Therefore, we decided that the Plan does not have to pay for ambulance 
response and treatment with no transport provided on January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 an office visit provided 
on November 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab and venipuncture services, and a shoulder x-ray provided 
on September 15, 2022. 
 
You asked the Plan to pay for lab and venipuncture services, and a shoulder x-ray. You say that you think that 
this provider is in-network. 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 lab and venipuncture 
services, and a shoulder x-ray provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a bath/shower chair. You say that the member is disabled and this durable 
medical equipment was referred by the members physician. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spine surgery. 
 
You asked the Plan to pre-approve the spine surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 spine surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there is no documentation of adequate conservative measures for back pain; at least 3 months of 
back pain treatment 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 spine surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the spine surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take home supply of methadone provided on December 26, 
2022. 
 
You asked the Plan to pay for take home supply of methadone. You say that you are requesting a 
reconsideration of the denied charges. 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 take home supply of 
methadone provided on December 26, 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. You say that the enrollee needs physician oversight and intense 
therapy. The enrollee is very motivated to participate. The Plan denied your request. The Plan says ongoing 
skilled care can be provided in an alternative setting. 
 
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 the clinical documentation shows that the enrollee has complex functional 
impairments however no active medical comorbidities have been specified. The complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria is not met. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on January 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you chose 
to permit the medical technicians to return to their home base and they assured you that you could call them at 
any time later that morning if your condition worsened. You also say that you request that in this instance, you 
pay the invoice. 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 January 4, 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 ambulance response and treatment with no 
transport provided on January 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tocilizumab (J3262). 
 
You asked the Plan to pre-approve tocilizumab. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says that there is not enough evidence in the medical literature to show that 
the requested drug will improve the enrollees long-term health outcomes.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 tocilizumab. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the requested use of tocilizumab 
is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia 
or by clinical research that appears in a CMS-approved medical journal.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tocilizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tocilizumab (J3262).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on November 04, 2022. 
 
You asked the Plan to pay for a psychotherapy visit. You say that you are requesting a reconsideration of the 
denied charges. 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 a psychotherapy visit 
provided on November 04, 2022.
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 services are medically necessary for 
the enrollee to receive physician assessment and health management for their chronic ill status. The Plan denied 
your request. The Plan says the enrollee's medical needs are being met in the current setting.  
 
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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving somewhat with treatment but is still unstable for 
transfer and requires short-term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at 
the LTACH that are not already available at the current facility. Completion of treatment at the current facility 
is recommended.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite and crown provided on November 
15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed if the claim was sent in after 
January first it would be paid. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 7, 2022. Therefore, 
we decided that the Plan does not have to pay for the resin-based composite and crown provided on November 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64624 provided on January 25, 2023. 
 
You asked the Plan to pay for procedure code 64624. 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. The rules say that procedure code 64624 is limited to specific diagnosis 
codes that support medical necessity. 
 
We looked at the file and Medicare rules. Billed diagnosis code M17.0 is not listed as supporting medical 
necessity for billed code 64624. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
64624 provided on January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose vein treatment. 
 
You asked the Plan to pre-approve varicose vein treatment. You say that the requested varicose vein treatment 
is medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria.  
 
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 varicose vein treatment. Our reviewer 
says that the enrollee does not meet criteria.  Our physician reviewer found the documentation does not meet 
coverage criteria and does not support the medical necessity of the treatments in question. Foremost, it is not 
possible to attribute the enrollees leg pain to varicose veins without an assessment of lower extremity arterial 
perfusion. The appropriateness/medical necessity of any venous procedures, particularly for a person with 
multiple risk factors for peripheral artery disease including hypertension, dyslipidemia, and diabetes cannot be 
supported with the current documentation. It is not documented that the enrollee is having lifestyle limiting 
symptoms despite the use of compression stockings. There does not appear to be a demonstration of saphenous 
reflux in the right leg therefore the request for right saphenous ablation is unclear.  As it is noted that the left 
leg is more symptomatic than the right, it is unclear if there are any significant symptoms on the right.  Lastly, 
the health plan does not provide for simultaneous treatment of saphenous reflux and tributary vein treatments 
such as sclerotherapy.  For sclerotherapy to be considered medically necessary, there would need to be 
documentation of persistent symptoms severe enough to impact mobility or quality of life despite the use of 
compression stockings and despite successful ablation of the saphenous reflux with these symptoms persisting 6 weeks after saphenous treatment.  In summary, the documentation does not meet coverage criteria and does 
not support the medical necessity of lower extremity vein treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of varicose vein treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve varicose vein treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the relining of complete 
maxillary/mandibular dentures (D5751, D5750) provided on March 3,  2023. 
 
You asked the Plan to waive the copayment the dental services. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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. 
 
You have been asked to pay a 50% coinsurance for denture relining services (D5751, D5750). This 
item/service falls within the Dental Services 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 the relining of complete maxillary/mandibular dentures (D5751, D5750) provided on March 3,  2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for fillings (D2330, D2392, D2391) provided on January 
19, to February 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for fillings (D2330, D2392, D2391) provided on 
January 19, to February 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that you should 
not have to pay this copayment because you have insurace. 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 $250 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. 
 
You have been asked to pay a $250 copayment for an in-network diagnostic colonoscopy. This item/service falls within the outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility 
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 in-network diagnostic 
colonoscopy provided on February 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be in a rehab facility, you don't need to 
be in a nursing home where you can't get any help. The Plan denied your request. The Plan says your records 
do not show that your rehab needs are complex and that you need to be seen 3 times per week for evaluation of 
functional and medical goals and progress. You do not need an intensive team for your care. It is not reasonable 
to assume, based on your current level of function, that you will be able to take part in 3 hours of therapy 5 
days per week as you are limited by pain. The services you need can be provided safely in other settings, for 
example, 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.