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

 
We decided that the Plan does not have to pay for debridement of nails provided on December 20, 2022. 
 
You asked the Plan to pay for debridement of nails. You say that the records attached support the 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 debridement of nails 
provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on December 
08, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the 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 subsequent nursing 
facility care visits provided on December 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 31, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should 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 laboratory testing 
provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies and related services provided on 
October 06, 2022. 
 
You asked the Plan to pay for nerve conduction studies and related services. You say that these services were 
medically necessary. 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 nerve conduction studies 
and related services provided on October 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 12, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the 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 lab testing provided on 
October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal evaluation (D0180) and the panoramic 
radiographic image (D0330) provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist office searched your benefits, and it 
showed you had 1 benefit remaining and you should not be responsible for the miscommunication. The Plan 
denied your request. The Plan says your benefit for the requested items or services 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 the Plan paid for a panoramic radiographic image on September 13, 2019; therefore, your benefit for the 
panoramic radiographic image was exhausted on the date of service of September 13, 2019. The record also 
shows the Plan paid for a periodontal evaluation on January 6, 2022; therefore, your benefit for the periodontal 
evaluation was exhausted on the date of services of January 6, 2022. Therefore, we decided that the Plan does 
not have to pay for the periodontal evaluation (D0180) and the panoramic radiographic image (D0330) 
provided on January 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an occupational therapy (OT) visit 
provided on January 27, 2023. 
 
You asked the Plan to waive the copayment for an occupational therapy (OT) visit. You say that you did not 
have any therapy services performed during this visit. 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 $30 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $30 copayment for an occupational therapy (OT) visit. This item/service falls 
within the outpatient rehabilitation service 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 occupational therapy (OT) visit provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370, 
77373). 
 
You asked the Plan to pre-approve SBRT. You say that treatment of stereotactic radiation would provide the 
best outcome for the enrollee's cancer type. The Plan denied your request. The Plan says Medicare guidelines 
are not supportive for SBRT to treat low volume metastases. The request does not meet the Medicare or health 
plan coverage criteria. There is evidence that this type of radiation is not needed and not effective for the 
enrollee's cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the benefit of SBRT perhaps remains controversial, particularly in light of the recent negative 
NRG BR002 study that showed no benefit with respect to progression free survival in women treated with 
standard of care systemic therapy with or without SBRT for breast cancer oligometastases to any site. There 
was a significant benefit with respect to progression free survival with the addition of SBRT for lung cancer 
but not for breast cancer, with the authors concluding no benefit of SBRT. Overall survival was not reported. In 
summary, SBRT in the setting of widely metastatic disease would not be considered to be furnished in 
accordance with accepted standards of medical practice. As such, the decision is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT) (77370, 77373).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on 
September 08, 2022. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you received services 
provided in an ambulatory surgical center. 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 $325 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the cataract surgery. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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. The record shows you 
received services provided in a hospitals surgical center. Therefore, we decided that the Plan does not have to 
reduce the copayment for the cataract surgery provided on September 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Emerg - Air Immersion Therapy Mattress. 
 
You asked the Plan to pre-approve the Emerg - Air Immersion Therapy Mattress. You say that the requested 
item is not a group 3 mattress. You say that the requested mattress would be the best option for the enrollee as 
she does not have 24-hour care and is occasionally independent with transfers. You say that a group 3 mattress 
is not appropriate for the enrollee's condition. The Plan denied your request. The Plan says they would cover a 
group 3 pressure reducing surface if the provider coded their pre-authorization request appropriately. 
 
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 Emerg - Air Immersion Therapy 
Mattress. Our reviewer says that the Emerg - Air Immersion Therapy Mattress is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that notes from April 24, 2023, indicate that the enrollee is healing on a low air loss mattress and a negative pressure wound dressing. It is not evident 
from the records provided that a more advanced mattress is medically 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 Emerg - Air Immersion Therapy Mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Emerg - Air Immersion Therapy Mattress.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 1, 
2021, to May 4, 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 the payment integrity post-service, post-payment PDPM clinical validation audit found 
that the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective Payment 
System (HIPPS) Score 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support that the enrollee has the pertinent 
medical diagnosis to support the proposed PDPM code. There is no evidence of shortness of breath when lying 
flat or an active diagnosis of respiratory failure. The documentation does not support the billed functional 
scores. The proposed PDPM code of KDBC1 was not correct. The partial adjustment to PDPM LAQE1 was 
appropriate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from May 1, 2021, to May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chair lift provided on August 26, 2022. 
 
You asked the Plan to waive the coinsurance for the chair lift. You say that the chair lift was medically 
necessary. 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 40% 
coinsurance for out-of-network durable medical equipment and related supplies. 
 
You have been asked to pay 40% coinsurance for the chair lift. This item/service falls within the out-of-
network durable medical equipment and related supplies 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. The total you owe is $125.24 ($313.09 allowed amount x 40% = $125.24). Therefore, we decided that the Plan does not have to waive the coinsurance for the chair lift 
provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on October 17, 2022. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this was medically necessary and should 
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 genetic laboratory 
testing provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on 
September 13, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the 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 subsequent nursing 
facility care visits provided on September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide bathing services. 
 
You asked the Plan to pre-approve aide services. You say that you do not have the stability to bathe yourself. 
The Plan denied your request. The Plan says that the rules have not been followed and the application is not 
covered in this moment. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of aide services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health 
aide bathing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the 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 an office visit provided 
on February 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epifix (Q4186) and skin graft (15275). 
 
You asked the Plan to pre-approve the epifix and skin graft. 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 epifix and skin graft. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has an ankle-brachial index (ABI) of 0 in the left leg due to severe 
Peripheral Arterial Disease (PAD) which is not conducive to viability of grafting in that area. 
 
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 epifix and skin graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the epifix (Q4186) and skin graft (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 12, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. 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 office visit provided on 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 19, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary. 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 nursing facility care 
provided on January 19, 2023.