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

 
We decided that the Plan does not have to pay for nursing facility care provided on March 16, 2023, by an 
OON provider.  
 
You asked the Plan to pay for nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan contract also says that the enrollee's POS benefit only 
applies to routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on March 16, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have lymphedema extending onto 
the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, 
trunk and/or abdominal lymphedema has failed to improve with a four- 
week trial. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found this enrollee's condition is complex and fragile. There is every reason to expect that the enrollee will 
participate in and benefit from services to include at minimum physical therapy (PT), occupational therapy 
(OT), respiratory therapy, nutritionist, physician oversight of her cardiopulmonary and nutritional orders, and 
case manager coordination of any additional service she might need to finally make a sustainable return home 
at a more normal level of function than she entered the hospital at 3+ months ago. Skilled nursing facility 
(SNF) placement would be inappropriate to meet her needs, and home therapies would be very premature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic knee brace provided on April 26, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the orthotic knee brace. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services.  
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the orthotic knee brace provided on April 26, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on February 21, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the specialist office visit. You say that you were unaware a prior authorization 
was needed. The Plan denied your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The 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 specialist office visit provided on February 21, 
2023, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on November 03, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 November 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk without assistance and need 
inpatient rehabilitation to become stronger and be able to function daily without assistance being home alone. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation Facility. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says records do not show that the pain characteristics are consistent with 
vertebrogenic pain and not caused by another source, such as facet arthropathy or spinal stenosis, both of which 
were consistent with the enrollee's physical exam findings and were seen on magnetic resonance imaging. 
Additionally, modic changes were not described on lumbar magnetic resonance imaging. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on March 16, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 office visit (99214) provided on March 16, 2023, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of benign tumor or cyst of mandible, by 
enucleation and/or curettage (21040). 
 
You asked the Plan to pay for the dental service. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the dental service is not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the excision 
of benign tumor or cyst of mandible, by enucleation and/or curettage (21040).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way (rotary wing) and rotary wing air mileage provided on October 8, 2022. You asked the Plan to pay for the ambulance service and rotary wing air mileage. You say that based on 
clinical documentation and a registered nurse who has multiple years of critical care field experience, believes 
this transport meets medical necessity guidelines. The Plan denied your request. The Plan says after reassessing 
the entire clinical situation, information provided at the time of the appeal does not support criteria for air 
ambulance transport. There are multiple closer facilities with appropriate services to treat the enrollee.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 ambulance service and rotary wing air 
mileage . Our reviewer says that the air ambulance services were not medically necessary. Our physician 
reviewer found after several days of treatment in the intensive care unit the decision was made to transfer the 
enrollee. Upon evaluation, the critical transport unit declined to transfer the enrollee, resulting in an air 
ambulance being contacted. It appears that the provider believed the enrollee was stable enough to be 
transported by ground. It is unclear why the critical transport declined to transfer the enrollee. It is also not 
noted why closer facilities were not appropriate for the transfer. As such, the entirety of the record does not 
support that the provided air transport was medically necessary and reasonable. 
 
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 ambulance service and rotary wing air mileage  have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, conventional air services, 
transport, one way (rotary wing) and rotary wing air mileage provided on October 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aqua motion therapy to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve aqua motion therapy. You say that you do not agree with the denial for aqua 
motion therapy. The Plan denied your request. The Plan says the service can be provided by an in-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 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 
aqua motion therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on 
January 18, 2023. 
 
You asked the Plan to waive the deductible for the outpatient clinic visit. You say that you are being charged 
more than the provider is billing the Plan. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to outpatient hospital services.  
 
The cost sharing applied is based on the Medicare allowed amount. You have been asked to pay $132.92 
towards the deductible. The item or service you asked the Plan to waive the deductible for falls within the 
physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to outpatient hospital services. This cost sharing is a 
contractual obligation that had not been met at the time the outpatient clinic visit was received on January 18, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient clinic visit 
provided on January 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 61.2 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transition lens enhancements and antiglare lens 
enhancements (V2799) provided on February 15, 2023. 
 
You asked the Plan to pay for transition lens enhancements and antiglare lens enhancements (V2799). You say 
that you called the Plan and was told you need to submit the original bill for reimbursement. The Plan denied 
your request. The Plan says this lens options is not covered without the purchase of a base lens. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the ultraviolet protection and scratch resistant coating are included in the eyeglass 
allowance benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that ultraviolet protection and scratch resistant 
coating are included in the eyeglass allowance benefit. Transitions and antiglare on lens only are excluded from 
this benefit. Based on this information, we decided that the Plan's rules for coverage of miscellaneous vision 
service (V2799) have not been met. Therefore, we decided that the Plan does not have to pay for transition lens 
enhancements and antiglare lens enhancements (V2799) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92012) provided on February 9, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a medical eye examination (92012). You say that the enrollee was in a nursing 
home setting at the time services were rendered. You also say the enrollee could not choose an in-network 
optometrist as they do not provide services in the residence. The Plan denied your request. The Plan says 
services were not authorized by network/primary care providers. The Plan also says that this provider is not a 
network provider with the Plan and the services were not referred by a network provider or rendered in an in-
network facility.  
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 a medical eye examination (92012) provided on 
February 9, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve stomach peroral endoscopic myotomy (43999). 
 
You asked the Plan to pre-approve stomach peroral endoscopic myotomy. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 stomach peroral endoscopic myotomy. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found peroral endoscopic myotomy of the stomach is now recognized by national 
clinical guidelines as safe, effective, and medically appropriate for medically refractory gastroparesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stomach peroral endoscopic myotomy have been met. Therefore, we decided 
that the Plan has to pre-approve stomach peroral endoscopic myotomy (43999).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.