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

 
We decided that the Plan does not have to pre-approve an office visit with an out-of-network ophthalmologist. 
 
You asked the Plan to pre-approve the out-of-network ophthalmologist visit.. You say that you need to see a 
neuro-ophthalmologist, which your medical group does not have. The Plan denied your request. The Plan says 
the requested service can be provided in-network. The Plan also says that the requested service is not urgent or 
emergent.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 out-of-network ophthalmologist 
visit. Our reviewer says that the request to see an out-of-network ophthalmologist is not medically necessary. 
Our physician reviewer found the record supports that the Plan providers are qualified to provide the requested 
treatment. The reviewer found that the enrollee has retina-related ophthalmic conditions of which the in-
network ophthalmologists offered by the plan are equally qualified as the out-of-network ophthalmologist. The 
reviewer found that you have indicated you need to see a neuro-ophthalmologist. The provided documentation 
does not suggest a referral to a neuro-ophthalmologist was needed nor recommended. The requested out-of-
network ophthalmologist is a vitreoretinal ophthalmologist, and not a neuro-ophthalmologist. Therefore, the 
reviewer found that the request to see an out-of-network ophthalmologist is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the out-of-network ophthalmologist visit. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an office visit with an out-of-network ophthalmologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network transthoracic echocardiogram 
(TTE) provided on January 24, 2023. 
 
You asked the Plan to waive the cost for an in-network transthoracic echocardiogram (TTE). You say that your 
provider did not agree with the fact that you had this test done, and thought it was unnecessary. You should not 
have to pay this large copay. 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 $750 
deductible for outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay $441.66 towards your deductible for an in-network transthoracic echocardiogram 
(TTE). This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 
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 cost for an in-network transthoracic 
echocardiogram (TTE) provided on January 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the preferred agents would be less effective and/or cause 
adverse effects. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Orthovisc or Supartz FX before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trivisc.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on January 24, 2023. 
 
You asked the Plan to pay for the mental health services. You say that you are requesting reconsideration of the 
denied claim. 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 mental health 
services provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary/mandibular denture (D5120, D5110) 
provided on January 24, 2023. 
 
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 the services denied correctly as they were 
performed by a denturist. 
 
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, fees for dentures provided by someone 
other than a dentist are a benefit exclusion. The records provided show that the dentures in dispute were 
provided by a denturist and not a dentist.  Therefore, we decided that the Plan does not have to pay for a 
complete maxillary/mandibular denture (D5120, D5110) provided on January 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement (procedure code 36222) 
rendered on January 27, 2023. 
 
You asked the Plan to pay for the services. You say that the medical records should be reviewed. The Plan 
denied your request. The Plan says the denied code is not supported in the 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 36222 is "Selective catheter placement, common carotid 
or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid 
circulation and all associated radiological supervision and interpretation, includes angiography of the 
cervicocerebral arch, when performed." 
 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 documentation does not make 
any mention of the carotid artery, but only the femoral artery with the selective angiogram. There is a more 
appropriate procedure code to use for this situation. 
 
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 selective catheter placement (procedure code 36222) rendered on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture service provided on January 19, 2023, to 
January 30, 2023. 
 
You asked the Plan to pay for acupuncture service. You say that it is medically necessary. The Plan denied 
your request. The Plan says the Plan has limited acupuncture benefits and these services are excluded. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the medical records provided do not demonstrate that 
the acupuncture services in dispute were for treatment of chronic lower back pain. Therefore, we decided that 
the Plan does not have to pay for acupuncture service provided on January 19, 2023, to January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcranial doppler study of the intracranial arteries and a 
duplex scan of extracranial arteries; complete bilateral study provided on February 28, 2023. 
 
You asked the Plan to pay for the transcranial doppler study of the intracranial arteries and a duplex scan of 
extracranial arteries; complete bilateral study. You say that no payment was made on this claim. 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. The 
enrollees contract with the Plan says that there is a $750 deductible which applies to most covered services.  
 
 The item or service you asked the Plan to pay for falls within the covered benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
most covered services. This cost sharing is a contractual obligation that had not been met at the time the 
transcranial doppler study of the intracranial arteries and a duplex scan of extracranial arteries; complete 
bilateral study was received on February 28, 2023. Therefore, we decided that the Plan does not have to pay for 
a transcranial doppler study of the intracranial arteries and a duplex scan of extracranial arteries; complete 
bilateral study provided on February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen (J1459). 
 
You asked the Plan to pre-approve Privigen. You say that you are requesting an urgent appeal for the denial of 
Privigen for the treatment of  refractory sclerosis and scleroderma complicated by interstitial lung disease. The 
Plan denied your request. The Plan says neither Medicare nor the Plan covers this request. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Privigen. Our reviewer says that the 
requested use of Privigen is not supported. Our physician reviewer found Privigen is indicated for the treatment 
of adults with chronic inflammatory demyelinating polyneuropathy (CIDP) to improve neuromuscular 
disability and impairment. The review has determined that the requested use of Privigen is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen (J1459).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on January 3, 2023 to 
January 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient surgery services. You say that this is covered by Medicare. The Plan 
denied your request. The Plan says this 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 outpatient surgery services provided on January 3, 
2023 to January 31, 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 outpatient mental health provided on January 23, 2023. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting the submitted 
documentation be reviewed. 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 outpatient mental health 
provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 22, 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 the records do not support the services billed. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 enrollee was evaluated 
following a stroke. There was a limited history. The decision making was not complex, as risk of morbidity or 
mortality from the illness, co-morbidities or the diagnostic procedures was not high. The enrollee was more 
than 24 hours post-stroke and was not undergoing any major intervention. 
 
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 initial hospital care (procedure code 99223) rendered on August 22, 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 the enrollee's clinical condition meets full inpatient 
acute rehabilitation criteria, and their diagnosis is Medicare compliant for an acute rehabilitation level of care. 
The Plan denied your request. The Plan says 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 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury or surgery to the knee, or that the knee is unstable. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has not had a recent injury or surgery to the knees. The enrollee is ambulatory, but there 
is no evidence of objective true joint laxity or instability. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72040, 70100, 70310, 71045) provided 
on January 4, 2023. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 72040, 70100, 70310, & 71045 is not supported in the medical record. Specifically, the 
claim was billed with place of service 11 (office or other outpatient setting), however the records show this was 
provided in a mobile setting at a skilled nursing facility. Based on this information, we decided that Medicare 
rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (72040, 70100, 70310, 71045) provided on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1399). 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says this request is 
not medically necessary because the records show the enrollee does not have a prescription for the requested 
device. The Plan also says that the request is for a miscellaneous durable medical equipment (E1399) rather 
than a code that is covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if the supplier does not receive the 
order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Specifically, there is no prescription provided within the 
documentation for this requested power scooter. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (E1399).