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

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
20, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were evaluated for 
heat exposure and transportation was refused at the time. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 20, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on August 10, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. 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 subsequent nursing 
facility care. provided on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation, revision or repositioning of tunneled 
intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable 
reservoir/infusion pump; with laminectomy (62351). 
   
You asked the Plan to pre-approve implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; 
with laminectomy. You say that this is medically necessary. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implantation, revision or repositioning 
of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or 
implantable reservoir/infusion pump, with laminectomy. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed 
documentation is not clearly evident regarding failure of the pain pump. There is an intrathecal pain 
myelogram/pump study from September 19, 2023, which demonstrated no impediment of flow at the catheter 
tip, which was the indication for the procedure per the provider. 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 implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; 
with laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication 
administration via an external pump or implantable reservoir/infusion pump; with laminectomy (62351).
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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says that the enrollee does not meet the requirements for an LTACH 
admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation provided does not support that the enrollee requires services 
at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current heath care setting being offered by the plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services. provided on June 30, 
2023. 
 
You asked the Plan to pay for chronic care management services.. You say that this was the only provider 
available to render the services via televideo. 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 chronic care 
management services. provided on June 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient hospital services provided on 
June 14, 2023. 
 
You asked the Plan to waive the cost share for outpatient hospital services. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible and a 10% coinsurance which applies to outpatient 
hospital services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient hospital services 
benefit category. You are being asked to pay $142.66 towards your deductible and coinsurance. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible and a 10% 
coinsurance which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time outpatient hospital services was received on June 14, 2023. Therefore, we decided that 
the Plan does not have to waive the cost share for outpatient hospital services provided on June 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart for 
calcium scoring. 
 
You asked the Plan to pre-approve the CT scan. You say that the test is needed to find out why your heart is 
skipping. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is insufficient support in the peer-
reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation 
of coronary calcium in guiding optimal management of this condition. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart for calcium scoring.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation. You say that the enrollee has failed 
multiple other treatments in the past including physical therapy, two previous knee intra-articular corticosteroid 
injections, one previous knee intra-articular Durolane injection with ultrasound guidance, and use of 
meloxicam. The Plan denied your request. The Plan says the genicular radiofrequency ablation is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular radiofrequency ablation. 
Our reviewer says that the genicular radiofrequency ablation is not medically necessary. Our physician 
reviewer found that the genicular nerve block is the subject of ongoing clinical trials and is considered 
experimental therapy. 
 
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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the genicular radiofrequency ablation.
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 requires intensive physical therapy. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (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 
was admitted for lumbar spine surgery. Medical problems are stable. 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 this 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary because the records 
show the enrollee does not have a QMax of less than or equal to 15mL/s4.  
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of prostate can be 
covered when specific criteria 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found 
the record indicates that the enrollee has benign prostatic hypertrophy with lower urinary tract symptoms. The 
record provided is insufficient to establish that all of the required elements of the coverage criteria are 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 transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrodesis (22551), the anterior instrumentation (22845), 
the insertion of interbody biomechanical device (22853), the allograft (20930), and the autograft for spine 
surgery (20936) provided by Barbara Ortega-Rutherford, RN, on June 6, 2023. 
 
You asked the Plan to pay for the services provided by Barbara Ortega-Rutherford, RN. You say that the 
leading surgeon ordered the services of the assistant and prior authorization was obtained. The Plan denied 
your request. The Plan says the provider is not participating in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
arthrodesis (22551), the anterior instrumentation (22845), the insertion of interbody biomechanical device 
(22853), the allograft (20930), and the autograft for spine surgery (20936) provided by Barbara Ortega-
Rutherford, RN, on June 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73110 provided on July 26, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 73110 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 procedure code 73110 provided on July 26, 2023, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services provided on December 8, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the colonoscopy services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network 
care. 
 
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 colonoscopy services provided on December 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from MAY 15, 2023, through MAY 29, 2023. 
 
You asked the Plan to pay for the IRF care. You say that admission is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the medicals record do not show the enrollee has the medical 
complexity, nor the necessary skilled rehabilitation needs, to warrant a multi-disciplined team of skilled 
therapists to have satisfied the requirements of an IPR admission. 
 
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 pay for the 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 medical 
records support 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. It 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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from MAY 15, 2023, 
through MAY 29, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided from August 1, 2019, to August 
15, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim was submitted over one year after the dates of 
service. 
 
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 SNF services was not filed until August 24, 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 SNF services provided from August 1, 2019, to August 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
17, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the enrollee was 
evaluated for heat stroke, but he was feeling better when the ambulance arrived. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no 
payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment. provided on June 27, 2023. 
 
You asked the Plan to pay for medication assisted treatment.. You say that this is the only opiod treatment 
program in the county. 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 medication assisted 
treatment. provided on June 27, 2023.