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

 
We decided that the Plan does not have to pay for the hip and femur x-rays provided on April 24, 2023. 
 
You asked the Plan to pay for the hip and femur x-rays. 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 hip and femur x-rays 
provided on April 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nonemergency ambulance transportation services. 
 
You asked the Plan to pre-approve nonemergency ambulance transportation services. 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 pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 nonemergency ambulance 
transportation services. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the documentation did not support that other means of transport (such as stretcher van, wheelchair van) 
were contraindicated for this enrollee on August 25, 2023. The documentation also does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on August 25, 2023. Therefore, the documentation does not 
sufficiently support that the ambulance transport on August 25, 2023, was medically reasonable and necessary 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nonemergency ambulance transportation services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve nonemergency ambulance transportation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology procedure provided on June 
09, 2022. 
 
You asked the Plan to pay for an unlisted molecular pathology procedure. You say that this service was 
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 an unlisted molecular 
pathology procedure provided on June 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 03, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the service 
provided. 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 lab testing provided on April 03, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 12, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say that the 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 lab testing provided on 
May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that it is medically necessary because the 
procedure will address the enrollee's symptoms of chronic back pain. The Plan denied your request. The Plan 
says medical studies have not proven this service/item is helpful for the treatment of the enrollee's health 
problem. 
 
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 an 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 (MRI) showing only modic changes without 
facet degenerative joint disease or stenosis. The cause of pain is not clear. Medicare guidelines are 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit and laboratory service provided on March 
21, 2023, by an OON provider.  
 
You asked the Plan to pay for the outpatient visit and laboratory service. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services were 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 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 outpatient visit and laboratory service provided 
on March 21, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient post stabilization provided on January 14, 2023, to 
January 22, 2023. 
 
You asked the Plan to pay for inpatient post stabilization. You say that the 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 inpatient post 
stabilization provided on January 14, 2023, to January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an orthopedic surgeon to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee must use network providers to get his medical care and services. 
 
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 
an office visit (99204) with an orthopedic surgeon to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on January 
27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that this is supported in the 
records. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on January 
27, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient C6-T1 posterior cervical discectomy fusion 
(22600, 22614, 63048, and 63045). 
 
You asked the Plan to pre-approve inpatient C6-T1 posterior cervical discectomy fusion. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 inpatient C6-T1 posterior cervical 
discectomy fusion. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found physical exam does not correlate with imaging 
showing spinal cord and nerve root compression. There is no myelopathy or radiculopathy that matches imaging. Surgery not needed and inpatient stay not 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 inpatient C6-T1 posterior cervical discectomy fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient C6-T1 posterior cervical discectomy 
fusion (22600, 22614, 63048, and 63045).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 19, 2023, to June 21, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that the services 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 physical therapy 
provided on April 19, 2023, to June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 02, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that coverage for 
the scan was approved and should not have a 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 $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. 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 
computed tomography (CT) scan provided on June 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found there was an indication of a suspicion 
of AD, but there was no mention in the records that FTD was suspected. The base requirement of the NCD 
would not be satisfied at this time. Therefore, this request cannot be determined to be reasonable and necessary 
as defined by the NCD. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 26, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that you are asking that this claim be paid as a 
courtesy, as services were provided in good faith. The Plan denied your request. The Plan says the services 
were not authorized. 
 The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care provided on June 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found there is no indication within the records 
provided for review that the enrollee is enrolled in or participating in any programs. In as much the request 
does not meet Medicare criteria for coverage at this time. 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiovascular monitoring 
services provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiovascular monitoring services. You say that 
you didnt see the doctor this day and shouldnt be charged. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits.  
You have been asked to pay a $40 copayment for an in-network cardiovascular monitoring services. This 
item/service falls within the Physician/Practitioner services, including doctors office visits 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. However, since the 
allowed amount is less than the standard copayment, you only owe $25.26. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network cardiovascular monitoring services provided on April 
04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift or glide.  
 
You asked the Plan to pre-approve a stair lift or glide. You say that you would like reconsideration because the 
requested stair lift is medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift or glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Revrofit Closure System described by code L5999. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services cannot be covered as requested. 
 
The Plan must follow Medicare rules. The rules say that use of L5999 is incorrect coding (unbundling). 
 
We looked at the file and Medicare rules. The file shows that the item has been requested with code L5999. 
This code cannot be used to request this item and cannot be approved as such. Therefore, we decided that the 
Plan does not have to pre-approve a Revrofit Closure System described by code L5999.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on April 24, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that you 
should only be charged one copayment since the two MRI scans were taken during the same 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 $180 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $180 copayment for a magnetic resonance imaging (MRI) scan. 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) scan provided on April 24, 2023.