Persius/hicric huggingface dataset:
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 this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease. The cause of the 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says the service was not approved. 
 
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 to be provided by an OON provider.
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's acute needs have been met 
and stabilized in the acute care setting and is stable to transfer to LTACH for the continuation of care in the 
long-term acute care setting. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950), and intraoral - comprehensive series 
of radiographic images (D0210) provided on June 8, 2023. 
 
You asked the Plan to pay for core buildup and intraoral - comprehensive series of radiographic images. You 
say that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup (D2950), and intraoral - comprehensive series of radiographic images (D0210) provided on June 8, 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says all services that would be provided in the LTACH are 
being provided in the current acute care setting which is already approved. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) and a 
determination of refractive state (92015) provided on May 18, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014) and a determination of 
refractive state (92015). You say that this should be covered by insurance. 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 $35 
copayment for Medicare-covered examination. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92014) and a determination of 
refractive state (92015). This item/service falls within the Medicare-covered examination 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 medical eye examination (92014) and a determination of 
refractive state (92015) provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory tests provided on May 19, 2023. 
 
You asked the Plan to waive the cost share for laboratory tests. You say that you disagree with the coinsurance. 
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 $250 deductible which applies to outpatient diagnostic 
tests/laboratory tests.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests/laboratory tests benefit category. You are being asked to pay $72.36 towards your $250 deductible. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which 
applies to outpatient diagnostic tests/laboratory tests. This cost sharing is a contractual obligation that had not 
been met at the time laboratory tests was received on May 19, 2023. Therefore, we decided that the Plan does 
not have to waive the cost share for laboratory tests provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
April 13, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you did not know that 
you were provided with an ophthalmologist not an optometrist. 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 $45 
copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye.  
You have been asked to pay a $45 copayment for a medical eye examination. This item/service falls within the 
Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye 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 medical eye examination provided on April 
13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Etoposide, Cisplatin, and Dexamethasone 
Sodium Phosphate. 
 
You asked the Plan to pre-approve Keytruda, Etoposide, Cisplatin, and Dexamethasone Sodium Phosphate. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested 
drugs are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Etoposide, Cisplatin, and 
Dexamethasone Sodium Phosphate. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has a 
diagnosis of metastatic poorly differentiated adenocarcinoma involving penis and liver which is PD -L1 
positive and has failed platinum-based therapy. The Food and Drug Administration has not stated that the 
requested drugs are indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drugs in the enrollee's clinical situation. Therefore, 
the enrollee does not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Etoposide, Cisplatin, and Dexamethasone Sodium Phosphate have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Etoposide, Cisplatin, 
and Dexamethasone Sodium Phosphate.
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 now ready for LTACH 
admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested foot inserts are medically 
necessary for your condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5212) provided on October 
13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plan's 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 benefit for the requested item or service was exhausted on date of service October 13, 2022 
(D5214). Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5212) 
provided on October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine testing. 
 
You asked the Plan to pre-approve nuclear medicine testing. You say that you are appealing the Plan's denial. 
The Plan denied your request. The Plan says this testing 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 nuclear medicine testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging (MRI) of the lower back and pelvis were ordered; 
however, results were not provided for review. The MRI results would help justify a bone scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nuclear medicine testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nuclear medicine testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 12, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you do not know why authorization would be 
needed for these services. 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 office visit provided on June 12, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided from March 23, 2023, to 
April 27, 2023.  
You asked the Plan to pay for transportation services. You say that the case manager automatically called for a 
chair car from the rendered provider each time you had an appointment. You also say that you assumed that 
your insurance paid for this service, and no one ever said it was not covered. The Plan denied your request. The 
Plan says the non-emergency transportation benefit is only available when received through the Plan network 
transportation provider. 
 
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 you schedule the service through a Plan network 
transportation provider.  
 
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. Therefore, we decided that the 
Plan does not have to pay for transportation services provided from March 23, 2023, to April 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 
2022, through October 9, 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 review indicates that the enrollee presented to the emergency department (ED) on 
October 8, 2022 with vertigo and presyncope. She was evaluated and admitted to the hospital for one day and 
had no identified laboratory or cardiac abnormalities. The enrollee remained stable. The orthostatics were 
negative. She required no further intervention and was discharged home after one night in the hospital. The 
enrollee was admitted for one day and was discharged after reassessment. 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 October 8, 2022, through October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on June 01, 2023. 
 
You asked the Plan to pay for wound care services. You say that you are requesting reconsideration of services 
denied for no authorization on file. 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 wound care services 
provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), and periodic oral evaluation - established patient (D0120) provided on June 15, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and periodic oral evaluation. You say that the 
provider did not send in the claim in a timely manner. The Plan denied your request. The Plan says the claim 
was submitted untimely. 
 
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 comprehensive oral evaluation and periodic oral evaluation was not filed 
until June 27, 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 comprehensive oral evaluation - 
new or established patient (D0150), and periodic oral evaluation - established patient (D0120) provided on 
June 15, 2022.