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

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and related services 
provided on January 17, 2023, to January 19, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that the enrollee 
could not choose an in-network provider. 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, and related services provided on January 17, 2023, to January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. The Plan denied your request. The Plan says based on the 
additional information available, the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET/CT scan. Our reviewer says that 
this request is not medically necessary. Our physician reviewer found there are only reports of the pathology 
report and no physician notes documenting why a PET scan was ordered. Our reviewer found that given this 
information from the pathology, there is no indication to perform a PET scan unless further documentation 
outlining the physician's decision making is reported. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed (E0265). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a total electric hospital bed (E0265) is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure address vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. 
The Plan says this 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate there is magnetic resonance imaging (MRI) showing only Modic changes. The reviewer found that there is no clear cause for the enrollee's 
pain. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on June 
21, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says without transport there are no payable 
services. 
 
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 June 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to process these services. 
The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until June 29, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for dental services provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that all of these services were medically necessary. 
The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service June 7, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on June 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a destruction by neurolytic agent. 
 
You asked the Plan to pre-approve a destruction by neurolytic agent. You say that this surgery would help with 
the enrollee's pain. The Plan denied your request. The Plan says this procedure 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 a destruction by neurolytic agent. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental procedure and is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 a destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a destruction by neurolytic agent.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient service. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says there are network provider's available. 
 
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) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drug. 
 
You asked the Plan to pay for the medication. You say that the enrollee has met all out-of-pocket costs and 
should not be billed for pharmacy items. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drug.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Self-Administered Drugs/Injections. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for Self-Administered 
Drugs/Injections.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on June 26, 2023. 
 
You asked the Plan to pay for medication assisted treatment. You say that a referral or authorization is not 
required. 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 medication assisted 
treatment provided on June 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on January 31, 2023. 
 
You asked the Plan to pay for initial nursing facility care. You say that the enrollee was in a nursing home at 
the time the services were rendered. 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 initial nursing facility 
care provided on January 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod. 
 
You asked the Plan to pre-approve Omnipod. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested medication is not a covered service under 
Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that they cover services that are medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Omnipod have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Omnipod.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 29, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on June 29, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that you would like Eylea to be approved for coverage. The 
Plan denied your request. The Plan says you do not have any stated contraindications to the preferred products. 
You have tried and failed Avastin, but have not tried and failed Byooviz. The Plan also says that the provider 
does not provide a rationale for use of the non-preferred product for safety or efficacy. 
 
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 Eylea. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Byooviz 
before they will approve the requested drug. In this case, you have not tried and failed the required drug. Our 
reviewer also found that there is no documentation provided indicating that the Plan's required drug would 
likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was filed late due to the time it 
took to get the enrollee's insurance information. The Plan denied your request. The Plan says the corrected 
claim was not received in the time frame for filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until May 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 18, 
2023, to January 20, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider. 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 provided on January 18, 2023, to January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a customized power wheelchair (PWC) base (K0013). 
 
You asked the Plan to pre-approve a customized PWC base. You say that the enrollee's current wheelchair is 
too big. You also say that the enrollee's current regular wheelchair does not fit through the doors of the house. 
The Plan denied your request. The Plan says a power wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a customized PWC base. Our reviewer says that the requested PWC base is not medically necessary. Our physician reviewer found the provided 
documentation indicates that you have difficulty with ambulation and currently use a manual wheelchair for 
mobility. However, there is a lack of documentation indicating your level of mobility and function and why 
you cannot use a cane or walker or manual wheelchair for mobility. There is no mobility assessment and 
insufficient documentation regarding your upper and lower extremity motor strength and range of motion. 
There is no indication that the requested power mobility device can be safely used and that your living situation 
allows appropriate accessibility for it. Therefore, the reviewer found that the requested power wheelchair base 
(K0013) is not 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 a customized PWC base have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a customized power wheelchair (PWC) base (K0013).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 13, 
2022, through December 14, 2022. 
 
 
  
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on December 13, 2022 with chest 
pain. The physician's impression was chest pain. The plan was a Cardiology consultation, aspirin, and serial 
troponin level testing. During the hospital stay, the enrollee remained hemodynamically stable and maintained 
adequate oxygen saturations on room air. She underwent a left heart catheterization which showed no active 
coronary disease. The enrollee was discharged home on December 14, 2022 with instructions for a follow up. 
The review has determined that the record did not show that at the time of the inpatient admission it was 
reasonable for the admitting physician to expect that the enrollees necessary hospital care (including earlier 
ED and/or observation care) would span two midnights with supporting documentation of the enrollees history 
and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. 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 the acute inpatient hospital care provided from December 13, 2022, through December 14, 
2022.