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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
  You asked the Plan to pre-approve SNF care. You say that the enrollee needs to be admitted to a SNF to care 
for their wound and to make sure it heals properly. You say that the enrollee also needs physical therapy to help 
with their mobility which can help with their bed sores. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Prolia provided on March 24, 2023. 
 
You asked the Plan to pay for  Prolia. You say that that the attached documentation for medical necessity 
should be reprocessed. The Plan denied your request. The Plan says that that services or supplies that are as 
determined by us, are experimental or investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan says the reason for denial is brown bagging. However, the 
records do not support that the enrollee was supplied the medication from a pharmacy. This means that the Plan 
did not provide a valid reason for denial. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find your favor. Therefore, we decided 
that the Plan has to pay for  Prolia provided on March 24, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on January 20, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you only paid a $15 copayment for 
previous injections. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B prescription drugs 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. The total you owe is $109.30, which is 20% of the allowed amount for a Medicare Part B injection 
($546.51 allowed x 20% = $109.30). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an injection provided on January 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 9, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
support the medical necessity for transport. The Plan denied your request. The Plan says our policy covers non-
emergency ambulance transportation when it is the only way to transport a member safely and adequately or if 
other means of transporting a member are unsafe due to a medical condition. This claim does not meet these 
requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service and ground mileage.  
 Our reviewer says the transportation via ambulance to a scheduled orthopedics appointment was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent 
layperson would not believe that immediate medical attention was required for someone who was being 
discharged from the hospital/emergency department.  
 
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 ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management provided on May 05, 2023. 
 
You asked the Plan to pay for the care management. You say that at the time services were provided the 
enrollee was residing in a nursing home. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the care management 
provided on May 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for a toxoid vaccine provided on March 30, 2023. 
 
You asked the Plan to pay for a toxoid vaccine. You say that you are seeking reimbursement. The Plan denied 
your request. The Plan says this is an administrative determination for non-coverage and is not based on 
clinical criteria for medical necessity. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a toxoid vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a toxoid vaccine. 
Therefore, we decided that the Plan does not have to pay for a toxoid vaccine provided on March 30, 2023.  
 
Benefits for a toxoid vaccine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 12, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the doctor provided service to the member in 
good faith and should be reimbursed for the services. The Plan denied your request. The Plan says no benefit 
coverage is available for virtual services performed by an out-of-network provider. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services 
out-of-network. Based on this information, we decided that the Plans rules for coverage of the telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image 
guidance, includes placement of intra-articular implant. 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant. You say that arthrodesis, sacroiliac joint, percutaneous, with image 
guidance, includes placement of intra-articular implant is medically necessary. The Plan denied your request. 
The Plan says the requested arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant is experimental, investigational or unproven. 
 
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 arthrodesis, sacroiliac joint, 
percutaneous, with image guidance, includes placement of intra-articular implant. Our reviewer says that the requested arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-articular 
implant is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
there is no sacroiliac (SI) joint instability, fracture, or lesion. SI joint fusion for degenerative back pain remains 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant have not been met. Therefore, we decided that the Plan does not have to 
pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-
articular implant.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) when performed and screening digital breast tomosynthesis, 
bilateral provided on May 16, 2023. 
 You asked the Plan to pay for screening mammography, bilateral (2-view study of each breast), including 
computer-aided detection (CAD) when performed and screening digital breast tomosynthesis, bilateral. You 
say that the services were medically necessary. The Plan denied your request. The Plan says according to CMS 
Other Insurance Records, the member has a primary health insurance plan effective April 1, 2022 to present. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made three 
(3) attempts to the other health insurance to obtain the explanation of benefits for the date of service  
May 16, 2023. A representative from the other health insurance advised the explanation of benefits (EOB) 
would be faxed, however upon retrieval the EOB was not for the requested date of service. As the secondary 
insurer, the Plan cannot be held responsible for screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) when performed and screening digital breast tomosynthesis, 
bilateral until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for screening mammography, bilateral (2-view study of each breast), including computer-
aided detection (CAD) when performed and screening digital breast tomosynthesis, bilateral provided on  
May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy, (15830) provided on April 4, 2023. 
 You asked the Plan to pay for the surgical service. You say that this should be reprocessed and paid in 
accordance with Medicare guidelines. The Plan denied your request. The Plan says prior authorization is 
required for this outpatient department (OPD) service. The Plan also says that claims for HCPCS code subject 
to required prior authorization (PA) submitted without a PA determination and a corresponding UTN will be 
automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that panniculectomy requires prior authorization.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service have not been met. The record indicates that the service at issue in this case 
was performed as part of a panniculectomy. There is no record that prior authorization was obtained for this 
service as required by Medicare. Therefore, we decided that the Plan does not have to pay for the excision of 
excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy, 
(15830) provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99214) and electrocardiogram 
(EKG (93010) provided on March 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the outpatient visits. You say that the electrocardiogram (EKG) was 
not administered properly. You say that the provider would not redo it. You say that the provider referred you 
to a cardiologist. You say they could not see you until after your scheduled surgery. You say that you found a 
cardiologist on your own. You also say that you should be refunded for this service. 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 reimburse you 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided 
that the Plan does not have to reimburse you for the office visit (99214) and electrocardiogram (EKG (93010) 
provided on March 15, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on April 30, 
2023, by an OON provider.  
 
You asked the Plan to pay for the chronic care management services. 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 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 chronic care management services provided on 
April 30, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Zip procedure.  
 
You asked the Plan to pre-approve the Aurora Zip procedure. You say that the Aurora Zip procedure is 
medically necessary. The Plan denied your request. The Plan says there are no high-quality studies that show 
that the Aurora Zip procedure is better than an open procedure. 
 
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 Aurora Zip procedure. Our reviewer 
says that the requested Aurora Zip procedure not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Aurora Zip procedure is experimental. More research is needed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Aurora Zip procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Aurora Zip procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from January 22, 2022, 
to February 9, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the enrollee provided the incorrect 
insurance information. You also say that you feel an exception should be made. The Plan denied your request. 
The Plan says five calls were made verifying if the claim had been received. The Plan says that each call 
advised that the claim had not been received and how to submit one. The Plan also says that the claim was filed 
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 inpatient hospital care was not filed until April 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 the inpatient hospital care provided from January 22, 2022, to 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 26, 2023. 
 
You asked the Plan to pay for office visit. You say that you say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients which should be covered for the medical treatments provided. 
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 office visit provided on 
January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manipulative treatment provided on February 13, 2023, to 
March 20, 2023. 
 
You asked the Plan to pay for manipulative treatment. You say that you say that the visits should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for manipulative treatment 
provided on February 13, 2023, to March 20, 2023.