Persius/hicric huggingface dataset:
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 you would benefit from the multidisciplinary 
approach provided at an IRF. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, but skilled therapies at a skilled nursing facility (SNF) may be approved upon request.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do 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 patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on July 20, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the out-of-network 
services were 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the mental health services provided on July 20, 2023, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections (64491, J1100, 77002). 
 
You asked the Plan to pre-approve repeat facet joint injections. You say that you are requesting reconsideration 
stating your pain will become worse without the injections. The Plan denied your request. The Plan says the 
request is not medically necessary because your records do not show that you are not a candidate for 
radiofrequency ablation. 
 
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 repeat facet joint injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have undergone two facet joint injections without documentation of at 
least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 
50% consistent improvement in the ability to perform previously painful movements and activities of daily 
living as compared to baseline measurement using the same scale. The review has determined that you do not 
meet criteria for approval of the requested RFAs. The requested procedures are 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 repeat facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat facet joint injections (64491, J1100, 77002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on January 9, 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 (G0471) provided on June 14, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and appropriate. 
The Plan denied your request. The Plan says no order was provided to support that these services were 
requested by a physician who is treating the enrollee and were medically necessary. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the limited records provided do not include a physician order. There is no documentation, 
therefore, to show that these services were medically necessary and were requested by a physician who is 
treating the enrollee. Therefore, we decided that the Plan does not have to pay for laboratory services (G0471) 
provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical connection between the wheelchair controller 
and two or more motors (E2311), expandable controller (E2377), and harness (E2313) transit package (K0108) 
and controller shroud (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and wheelchair accessories. You say that you are 
appealing on the grounds that Medicare has reviewed the request and found the requested service to be both 
medically necessary and covered, under Medicare guidelines. The Plan denied your request. The Plan says the 
upgraded electronics are not medically necessary as the approved power options come with their own switches. 
The transit package and controller shroud do not primarily serve a medical purpose.  
 
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 wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested upgraded electronics are not medically necessary as the 
enrollee has adequate strength to manage standard power drives. The transit package (K0108) and controller 
shroud (K0108) are not necessary for activities of daily living assistance in the home.  
 
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 upgraded electronics and wheelchair accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), and harness (E2313) transit 
package (K0108) and controller shroud (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) and 
push handles (K0108) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and push handles. You say that these features are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. The rules also state that convenience items are non-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 expandable controller and push 
handles. Our reviewer says that the requested features are not medically necessary. Our physician reviewer 
found the records show that the enrollee is capable of operating the power features using the standard switches. 
The push handles are not primarily medical in nature and are non-covered. 
 
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 expandable controller and push handles have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377) and push 
handles (K0108) for an approved power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient clinic visit provided on 
June 06, 2023, to August 22, 2023. 
 
You asked the Plan to waive the copayment for each outpatient clinic visit. You say that these services should 
be fully covered. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for each outpatient clinic visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $135 ($45 copayment 
x 3 visits = $135). Therefore, we decided that the Plan does not have to waive the copayment for each 
outpatient clinic visit provided on June 06, 2023, to August 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 29, 2022, 
to May 27, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with a Q code as required. 
 
The Plan follows Medicare rules. The rules say that for HHAs must report where home health services were 
provided by the appropriate Q code. We reviewed the file and the Medicare rules. We find that the home health claim was not submitted with the 
appropriate Q code as required. Based on this information, we find that the Medicare rules for payment of the 
claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from December 29, 2022, to May 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (CGM), includes all supplies and accessories (A4239) provided June 23, 2023. 
 
You asked the Plan to pay for the CGM and supplies. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 
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 pay for the CGM and supplies. 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. The requested service is not 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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for supply allowance for nonadjunctive, nonimplanted continuous glucose monitor 
(CGM), includes all supplies and accessories (A4239) provided June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for telehealth psychotherapy visits provided 
from October 26, 2022, to July 13, 2023. 
 
You asked the Plan to waive the copayments for psychotherapy visits. You say that these visits are not 
supposed to have a copayment. 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 $50 
copayment for physician/practitioner services, including doctors office visits.  
The total you owe is $450 ($50 x 9 = $450). 
 You have been asked to pay a $450 total copayment for telehealth psychotherapy visits. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 copayments for telehealth psychotherapy visits provided from October 26, 2022, to 
July 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the ophthalmology services . You say that your current conditions make 
traveling difficult. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology services to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 11, 2023. 
 
You asked the Plan to pay for the home health services. You say that this claim was submitted correctly and 
should be processed for payment. The Plan denied your request. The Plan says this claim was submitted with 
the incorrect type of bill listed. The Plan must follow Medicare rules. Medicare rules say that all HH PPS claims must be submitted with TOB 
0329. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. The record shows the claim was submitted with the 
incorrect TOB, 0323. Therefore, we decided that the Plan does not have to pay for the home health services 
provided on August 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service July 25, 
2023. 
 
You asked the Plan to pay for procedure code 20930. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 20930 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. 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 
20930 billed for date of service July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 30, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was 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 the drug testing 
provided on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 9, 2023, billed with 
procedure code 00537-QZ. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed code is inconsistent with the procedure 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the anesthesia services provided were denied as inconsistent with the procedures 
reported by the facility on this date of service. However, the documentation provided did not include proof of 
the procedures that were actually billed. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on August 9, 2023, billed with procedure code 00537-QZ.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that the service at issue was a necessity for your care. 
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 June 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 30, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transportation 
was unnecessary. 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 $150 
copayment for ambulance services. 
 
You have been asked to pay a $150 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on June 30, 2023.