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

 
We decided that the Plan does not have to pay for an ambulance response and treatment. provided on July 27, 
2023. 
 
You asked the Plan to pay for an ambulance response and treatment.. You say that the service was necessary to 
help you to get up after you had fallen. 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 an ambulance response 
and treatment. provided on July 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on September 24, 2023, to 
October 13, 2023.  
 
You asked the Plan to pay for home health services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that  
Our physician reviewer found the clinical documentation does not specify any appropriate home health skilled 
nursing goals, acute clinical status changes, medication or plan of care changes or complex wounds thus the 
records do not show that 61 (G0299) or 61 (G0300) additional home health skilled nursing visits are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on September 24, 2023, to October 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 01, 
2023, to August 28, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were unaware of the 
copayment at the time services were rendered. 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 $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for physical therapy. This item/service falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $210 for outpatient hospital rehabilitation visits ($30 
copayment x 7 visits = $210). Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy provided on August 01, 2023, to August 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation. provided on December 07, 2022. 
 
You asked the Plan to pay for ambulance transportation.. You say that you are requesting reconsideration based 
on medical necessity. 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 ambulance 
transportation. provided on December 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 20, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that the services should be paid separately. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 18 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, correctly 
coded, or medically necessary. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 billed for 
date of service June 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy (36471). 
 
You asked the Plan to pre-approve sclerotherapy (36471). You say that the enrollee has reoccurring aching, 
fatigue, swelling, heaviness which is affecting their daily activities which includes working on their farm.  The 
Plan denied your request. The Plan says sclerotherapy (36471) 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. The rules also say that treatments of the tributary veins are only covered when 
saphenous reflux is not present, when the veins are greater than 4 mm in diameter, and if the patient remains 
symptomatic after a six-week trial of conservative therapy. 
 
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 sclerotherapy (36471). Our reviewer 
says that sclerotherapy (36471) is not medically necessary. Our physician reviewer found that the records do 
not describe symptom nature or severity and does not include a pulse examination. Also, it is not possible to 
attribute the enrollee's leg symptoms to the varicose veins nor support the necessity of venous treatments 
without an assessment of lower extremity arterial perfusion.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy (36471) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sclerotherapy (36471).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel surgery in an outpatient hospital setting. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of uncontrolled hypertension or other high risk cardiovascular or 
general medical problems was provided in the available documentation. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not require this surgery in an outpatient hospital setting, instead of the plans 
approved ambulatory surgical center setting. The enrollee was being treated for right carpal tunnel syndrome. 
She presented with bilateral carpal tunnel syndrome, right worse than left. The exam reveals no change. There is positive Tinels, Phalens, and nerve compression bilaterally. However, limited published, large-scale, long-
term peer-reviewed literature shows this requested procedure needs to be performed in a hospital setting. The 
documentation even supports the procedure could be performed in an office setting over an ambulatory setting. 
Moreover, there is no significant past medical history documented. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the enrollee does not require this surgery in an outpatient hospital setting, 
instead of the plans approved ambulatory surgical center 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve carpal tunnel surgery in an outpatient hospital setting.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the procedure is medically necessary. 
You say that the enrollee has tingling and weakness in the back, buttocks and legs which greatly affects the 
enrollee's quality of life. The Plan denied your request. The Plan says the Vertiflex procedure is not medically 
necessary. The Plan says there is lack of evidence of the efficacy of interspinous fixation devices. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found was being treated for spinal stenosis of the lumbar region with neurogenic claudication. 
However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception.  
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation. provided on June 
27, 2023. 
 
You asked the Plan to pay for non-emergent ambulance transportation.. You say that you are appealing based 
on medical necessity. 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 non-emergent 
ambulance transportation. provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre kit 3 sensor. You say that this item is a medical 
necessity.  The Plan denied your request. The Plan says a CGM is not covered under Medicare if the enrollee is 
not on insulin, or does not have documentation of recurrent problematic hypoglycemia.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre kit 3 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or 
has problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. 
 
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 FreeStyle Libre kit 3 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre kit 3 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of carotid sinus baroreflex activation - 
Barostim Neo System (0266T and C1825) 
 
You asked the Plan to pre-approve the Barostim Neo System. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the Barostim Neo System is not medically necessary. The Plan 
says there is minimal support for using this device for heart failure to improve quality of life and functional 
outcomes. 
 
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 Barostim Neo System. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee with symptoms that are thought to be due to chronic systolic heart failure (CHF) despite medical management, in setting of severely reduced left ventricular function. There remains an absence 
of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in the enrollee's clinical management. 
 
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 Barostim Neo System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantation of carotid sinus baroreflex activation - Barostim Neo 
System (0266T and C1825)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 10, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panel tests must be billed 
with a single unit of service.  
 
We looked at the file and Medicare rules. This panel testing was not billed with a single unit of service. Based 
on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we 
decided that the Plan does not have to pay for laboratory testing provided on July 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on May 03, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are asking for a 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 physical therapy 
provided on May 03, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 06, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you would like reconsideration based on the 
records submitted. 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 September 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the upper spinal canal. 
provided on July 08, 2023. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI) of the upper spinal canal.. You say that you 
are requesting reconsideration. 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 magnetic resonance 
imaging (MRI) of the upper spinal canal. provided on July 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that patient would not benefit from receiving 
care at a lower level. Patient requires long term acute care with extensive monitoring. The Plan denied your 
request. The Plan says the LTACH criteria has not been met. 
 
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 patient is still unstable and requires additional acute care services that can safely 
be provided at the current facility until more stable and appropriate for transfer. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable and as it would not be clinically advantageous. Completion 
of treatment at the current facility is recommended.  
 
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the CT scans provided from August 22, 
2022, to February 6, 2023. 
 
You asked the Plan to waive the copayments for the CT scans. You say that you cannot afford the copayments. 
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 $225 
copayment for Medicare-covered diagnostic radiology services.  
 You have been asked to pay a $225 copayment for each CT scan provided on August 22, 2022, November 11, 
2022, and February 2023. These service fall within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. You have been asked to pay a total of $675 ($225 copayment x 3 scans = $675). 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 copayments for the CT scans provided from August 22, 2022, to February 
6, 2023.