Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a flexible protective outer surface covering system (L5964) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this denial was appropriate given the clinical scenario. 
 
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation does not support that the enrollee has a need for a specialized 
prosthetic cover due to being exposed to an unusually harsh environment. 
 
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 pay for a flexible protective outer surface covering system (L5964) provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T6 (22513) with fluoroscopic guidance 
(76000). 
 
You asked the Plan to pre-approve a kyphoplasty with fluoroscopic guidance. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when all the criteria listed in 
the Medicare rules section are met. 
 
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 a kyphoplasty with fluoroscopic 
guidance. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that 
there is no trial of bracing. More conservative measures are 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 a kyphoplasty with fluoroscopic guidance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a kyphoplasty at T6 (22513) with fluoroscopic guidance 
(76000).
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 LTACH level of care is appropriate 
and the only option for a safe discharge. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 pay for an office visit provided on April 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. 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 office visit provided 
on April 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Xgeva. Our reviewer says that the 
requirements for coverage of Xgeva have not been met. Our physician reviewer found the Plan requires a trial 
of intravenous pamidronate or zoledronic acid before they will approve Xgeva. The enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the required drugs would likely 
be less effective or 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile provided on 
June 16, 2022. 
 
You asked the Plan to pay for the non-covered ambulance mileage, per mile. You say that you would like these 
services to be a patient responsibility instead of a provider adjustment. The Plan denied your request. The Plan 
says Medicare law contains a restriction that miles beyond the closest available facility cannot be billed to 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that miles beyond the closest available facility cannot 
be billed to Medicare. Ambulance claims may use the -GY modifier online items for such non-covered 
mileage, and liability for the service will be assigned correctly to the beneficiary. We looked at the file and Medicare rules. The file shows that code A0888 was not billed with a GY modifier. 
Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile  
(codes A0888, A0425) provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion (22558, 22612, 22840, 22845, 22853). 
 
You asked the Plan to pre-approve spinal fusion. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 spinal fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no instability demonstrated in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion (22558, 22612, 22840, 22845, 22853).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on May 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services )41899, 93005, and J1100) you are asking the Plan to pay for involve the care, treatment, filling, 
removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services 
that are not covered or paid for by Medicare. Additionally, the rest of the claim is denied as the claim returned 
OCE edit 27. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on 
May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Minuteman interspinous device (20930, 
22612, 22840). 
 
You asked the Plan to pre-approve a Minuteman interspinous device. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 a Minuteman interspinous device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Minuteman device is experimental. More research is needed to 
demonstrate its safety and efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman interspinous device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve placement of a Minuteman interspinous device (20930, 22612, 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on January 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an eye exam. You say that the services provided should be covered. The Plan 
denied your request. The Plan says the 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 an eye exam provided on January 12, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 10, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the 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 laboratory services provided on August 10, 2022, 
by an out-of-network (OON) provider.
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 still in the intensive care unit (ICU) and 
needs the rehab. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram provided on November 29, 2022. 
 
You asked the Plan to pay for the electroencephalogram. You say that there was a misunderstanding and you 
thought you did not need prior authorization. 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 
electroencephalogram provided on November 29, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 for date of service December 6, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed are not payable. 
 
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. Review of the file shows that the Plan has denied this claim stating that with 
insufficient records, the medical necessity for a hospital admission cannot be established. The documentation 
shows that the service at issue was for emergency department visit. The documentation does not show why the 
emergency department visit was not covered. No other denial rationale was provided. Therefore, the Plan did 
not substantiate their denial. Therefore, we decided that the Plan has to pay for procedure code 99285 for date 
of service December 6, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for dialysis services provided from December 26, 2022, to  
December 30, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that the patient was visiting in San Diego and 
required dialysis treatment at to sustain life due to End-stage renal disease (ESRD). The Plan denied your 
request. The Plan says that 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. This provider is 
not a network provider with the Plan. We have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 has not provided a Plan rule that states out-of-area dialysis 
services are not covered. Therefore, we decided that the Plan has to pay for dialysis services provided from 
December 26, 2022, to December 30, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the wound repair services provided on 
February 07, 2023. 
 
You asked the Plan to reduce the copayment for the wound repair services. You say that this occurred during 
an urgent care visit. 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 $310 
copayment for outpatient surgery. 
 
You have been asked to pay a $310 copayment for the wound repair services. This item/service falls within the 
outpatient surgery 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 record shows this claim was approved and you are responsible for the cost share amount. 
Therefore, we decided that the Plan does not have to reduce the copayment for the wound repair services 
provided on February 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have lost over 20 pounds in muscle in the past 
three months due to an irritable bowel syndrome flare-up. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.