Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial hospitalization.  
 
You asked the Plan to pre-approve partial hospitalization. You say that partial hospitalization is medically 
necessary. The Plan denied your request. The Plan says partial hospitalization 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 partial hospitalization. Our reviewer 
says that the requested partial hospitalization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found based upon review the records provided, this enrollee was not showing any 
dangerousness to self or others and has not been exhibiting psychological or psychiatric impairment requiring 
this level of care. The enrollee was not showing any perceptual disturbance, psychosis or aggressive behaviors. 
It did not appear medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care rather than a lower level of care as the enrollee did not have any suicidal or 
homicidal thoughts or behavioral disturbance and her symptomatology could be treated at a lower level of care. 
The health Plans denial of continued partial hospitalization treatment for the dates in question appears 
appropriate. This enrollee did not appear to require partial hospitalization treatment. The enrollee was not 
showing any severity of psychological or psychiatric illness. Based upon review the records provided, this 
enrollee does not meet the criteria for treatment at partial hospitalization level of care and could be treated in a 
lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, and was not 
showing any psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve partial hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 29, 2022, 
to December 6, 2022, with the principal procedure originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal procedure of 0DV68DZ. 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 the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the documentation does not support the services billed. Our physician reviewer found 
the enrollee was admitted for generalized weakness/abdominal pain/anorexia Principal Procedure of 
0DV68DZ, which, per the CMS FY2023 IPPS Medicare DRG Grouper V40.0 Definitions Manual states that 
this service, Restriction of Stomach with Intraluminal Device, Endo, is never covered by Medicare. 
Additionally, per the CMS Claims Processing Manual Chapter 3 Section 20.2.1.D.11, "CMS does deny and 
return the entire claim when a non-covered procedure is present. Therefore, the services are not payable as 
billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 29, 2022, to December 6, 2022, with the principal 
procedure originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (VIA disc). 
 
You asked the Plan to pre-approve VIA disc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 VIA disc. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for intervertebral disc displacement of the lumbar region. He has 
chronic low back pain for 12 years as evidenced both midline and para midline back pain with flexion, sitting intolerance, pain with sit-to-stand transfer, pain with coughing, sneezing or bowel movement, pain in center of 
back, and pain is less when lying down. The pain is on average at 7 on RNS and 4 on VAS. 
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this 
request has beneficial outcomes compared with conventional treatment. Moreover, there are no objective exam 
findings provided for review to corroborate pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not have a diagnosis/condition that meets the criteria for the requested services and the requested 
VIA Disc, in this case, 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 VIA disc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (VIA disc).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 07, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not aware of 
this copayment and would not have used the ambulance if you had known. 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 $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on January 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair 
(E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that this feature is medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested feature is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair 
(E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy, and related services provided on December 
30, 2022. 
 
You asked the Plan to pay for physical therapy, 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 physical therapy, and 
related services provided on December 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided on 
August 16, 2022. 
 
You asked the Plan to pay for a positron emission tomography (PET) scan. You say that your facility is not 
liable to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a positron emission 
tomography (PET) scan provided on August 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on May 17, 2022. 
 
You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept services are medically necessary. The Plan denied your request. The 
Plan says the requested paramedic intercept services are not a covered benefit.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on October 24, 2022. 
 
You asked the Plan to pay for a rest home visit. 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 a rest home visit 
provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 18, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are asking to please reconsider paying these claims 
or you will be forced to try and recoup some of the money from the patients. 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 
January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and 
clearly exceeds the established criteria for LTACH level of care. The Plan denied your request. The Plan says 
the enrollee's records do not show that the current treatments required can only be given in a hospital setting. 
Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy, rigid or flexible, including fluoroscopic 
guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial rendered on October 5, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 31645 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 31645 is "Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial." 
 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 the reviewed operative report did 
not include documentation of an initial rigid or flexible bronchoscopy, including fluroscopic guidance, when 
performed with therapuetic aspiration of the tracheobronchial tree. The review has determined that the records 
did not support that CPT 31645 was rendered in this case. 
 
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 bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 
therapeutic aspiration of tracheobronchial tree, initial rendered on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health telehealth visit provided on February 16, 
2023, by an OON provider.  
 
You asked the Plan to pay for the telehealth visit. You say that this service was covered previously by an out-
of-network provider. The Plan denied your request. The Plan says that this service is not covered by an out-of-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you can receive certain out-of-network services through the POS benefit, however out-of-
network mental health telehealth services are not covered. 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 mental health telehealth visit provided on 
February 16, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 99379. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99379 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99379 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99379 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99379 billed for date of service September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each drug injection provided on September 
15, 2022, to September 22, 2022. 
 
You asked the Plan to waive the copayment for each drug injection. You say that you were told this would be 
fully covered if you went to the hospital. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $250 copayment for each drug injection. This item/service falls within the in-
network outpatient hospital 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. However, since the allowed amount is less than the standard copayment, you 
only owe $193.72 for each date of service. Therefore, we decided that the Plan does not have to waive the 
copayment for each drug injection provided on September 15, 2022, to September 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Evenity. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of post-menopausal osteoporosis. The documentation does not support that 
the enrollee has tried and failed Forteo. The documentation does not support that Forteo would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart, generally 
done prior to surgery (75572). 
 
You asked the Plan to pre-approve a computed tomography (CT) of the heart. You say that  requesting imaging 
for the enrollee to look for hypoattenuated leaflet thickening. The Plan denied your request. The Plan says the 
scan fails to meet the definition of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 computed tomography (CT) of the 
heart. Our reviewer says that the service is not medically necessary. Our physician reviewer found this request 
for a computed tomography (CT) will be considered 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 computed tomography (CT) of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart, generally done 
prior to surgery (75572).