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

 
We decided that the Plan does not have to pay for the nursing facility care provided on August 28, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that you are appealing the denial with 
supporting documentation. 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 the nursing facility care 
provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture visits provided on June 15, 2023, to June 22, 
2023. 
 
You asked the Plan to pay for acupuncture visits. You say that this was medically necessary for this patient, as 
it helped them. 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 acupuncture visits 
provided on June 15, 2023, to June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on October 11, 2022, to 
May 16, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 chiropractic services provided on October 11, 
2022, to May 16, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 29, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you were told that the patient is qualified 
for 20 acupuncture visits and the representative didnt say you were out-of-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 the acupuncture services 
provided on June 29, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 You asked the Plan to pre-approve Hymovis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Hymovis. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation provided on July 17, 2023. 
 
You asked the Plan to pay for the home visit for the evaluation. You say that you have attached medical records 
for medical necessity of the services. 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 the home visit for the 
evaluation provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on May 30, 2023. 
 
You asked the Plan to pay for the pain management services. You say that you had severe back pain and 
needed the procedure and you believe your health insurance should pay it. 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 the pain management 
services provided on May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
November 18, 2022, to November 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not told of 
the copayment. 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 inpatient hospital care. 
 
You have been asked to pay a $200 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a total of $400 for the inpatient hospital stay ($200 copayment 
x 2 days = $400). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on November 18, 2022, to 
November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care provided on July 10, 2023. 
 
You asked the Plan to pay for the wound care. You say that you are requesting reconsideration for services 
provided. 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 the wound care provided 
on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief and the procedure is medically necessary. The Plan denied your request. 
The Plan says the Intracept procedure is not medically necessary. The Plan says there are no Modic changes at 
L3 and there is non-vertebrogenic pain that could account for the pain. 
 
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 service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no Modic changes on the lumbar magnetic resonance imaging scans. 
 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the service is medically 
necessary. 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 in 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 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 
the pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and related supply 
allowance provided by an out-of-network provider on June 7, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided the 
medical records so the claim can be paid. The Plan denied your request. The Plan says the documentation 
requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. There is no information on the proof of delivery to tie it 
to the packing slip to verify what was delivered to the enrollee. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor (CGM) and related supply allowance provided by an out-of-
network provider on June 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 11, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
approved authorization. Also, the services rendered were 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 home health services provided on July 11, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intercept procedure for chronic low back pain. 
 
You asked the Plan to pre-approve intercept procedure for chronic low back pain. You say that this is medically 
necessary. The Plan denied your request. The Plan says there are ongoing clinical trials to look at how well 
people do after this procedure. This means it is investigational which means this is 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 pre-approve intercept procedure for chronic low 
back pain. 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 (MRI) showing 
only moderate changes without facet degenerative joint disease or 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 intercept procedure for chronic low back pain have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intercept procedure for chronic low back pain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief and the service is medically necessary. The Plan denied your request. The 
Plan says the Intracept procedure is not medically necessary. The Plan says there are no Modic changes at L4-5 
and there is non-vertebrogenic pathology that could account for the pain. 
 
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 service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) does not show Modic changes at L4-5. This means that 
the criteria 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle libre CGM system. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Freestyle libre CGM system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle libre continuous glucose monitor (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits, neck. 
 
You asked the Plan to pre-approve additional acupuncture visits, neck. You say that the enrollee needs 
acupuncture to treat neck pain. The Plan denied your request. The Plan says the enrollee has met the 
acupuncture visits benefit limit of 12 visits per year. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documents show you have been seen on the 
following dates of service for acupuncture, August 15, 2023, August 17, 2023, August 22, 2023, August 24, 
2023, August 31, 2023, September 12, 2023, September 19, 2023, September 26, 2023, October 5, 2023, 
October 12, 2023, October 19, 2023, and October 31, 2023. Therefore, your 12 visits have been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits, neck.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the chiropractic services. You say that you are requesting reconsideration of 
the denied service. The Plan denied your request. The Plan says the service was not approved. 
 
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 
the chiropractic services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services provided on June 13, 2023. 
 
You asked the Plan to waive the coinsurance for  dental services. You say that this should be covered in full. 
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 50% 
coinsurance for comprehensive dental services.  
 
You have been asked to pay 50% coinsurance for dental services. This item/service falls within the 
comprehensive 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 coinsurance for  
dental services provided on June 13, 2023.