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

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) at spine level L4-
5. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee has had many RFAs in 
the past with great relief. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because there was no information provided about the percentage and duration of pain relief 
from previous injections. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFAs may be covered when previous 
injections provided 50% or more improvement of pain and improvement in activities of daily living 
documented for at least 5 to 6 months. 
 
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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested repeat RFAs. Our physician 
reviewer found the most recent medical records state that the enrollee underwent a radiofrequency ablation 18 
months ago, and the physician appeal letter states that the enrollee has had many RFAs in the past. However, 
the records do not document that the enrollee has satisfied the coverage criteria for a repeat procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat radiofrequency ablation (RFA) at spine level L4-5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation, hot/cold pack, and mechanical traction 
therapies provided by a chiropractor from April 29, 2020, to June 15, 2020. 
 
You asked the Plan to pay for chiropractic services. You say that you are appealing all of these services. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these 
services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that 
they have approved payment for the office visit and chiropractic manipulative treatment services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for electrical stimulation, hot/cold pack, and mechanical traction therapies 
provided by a chiropractor from April 29, 2020, to June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation rendered from May 18, 2020 to 
June 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted a 
claim for procedure code G0283 (electrical stimulation). These services are not covered when performed by a 
chiropractor. Therefore, we decided that the Plan does not have to pay for the electrical stimulation rendered 
from May 18, 2020 to June 23, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit provided on May 19, 2020. 
 
You asked the Plan to pay for emergency department visit for the evaluation and management of a patient. You 
say that the claim was billed with the appropriate diagnosis which is payable as per guidelines. The Plan denied 
your request. The Plan says that the claim did not include the appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD diagnosis code.  
 
In this case, the ICD-10-CM diagnosis code T50.905 does not require additional diagnosis codes. Based on this 
information, we decided that Medicare rules for coverage of emergency department visit for the evaluation and 
management of a patient have been met. Therefore, we decided that the Plan has to pay for the emergency 
department visit provided on May 19, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers 60 one-way transportation trips per calendar year when each one-way trip does not 
exceed 75 miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging. 
 
You asked the Plan to pre-approve the gastrointestinal tract imaging. You say that the enrollee's upper 
endoscopy and colonoscopy did not explain the cause of his iron deficiency anemia. You say that further 
evaluation of this condition with a video capsule endoscopy is medically necessary to visualize for any source 
of obscure gastrointestinal bleeding that was not detected in the other testing. The Plan denied your request. 
The Plan says the requested services are 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 gastrointestinal tract imaging. Our 
reviewer says that gastrointestinal tract imaging is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 70-year-old man with a diagnosis of iron-deficiency 
anemia which was first identified about 3 years ago. The enrollee denied blood in his stools. There is no 
documentation of gastrointestinal bleeding. The enrollee is on iron supplementation. Laboratory studies were 
notable for a low Hct on June 15, 2020, and a normal Hct on July 15, 2020. An upper endoscopy on September 
14, 2020, revealed a large paraesophageal hernia. A colonoscopy on September 14, 2020, revealed 
diverticulosis. The documentation does not support that there is evidence of continued or recurrent 
gastrointestinal bleeding since the enrollee's upper and lower endoscopic examinations. 
 
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 gastrointestinal tract imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve gastrointestinal tract imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, prophylaxis, and periodic oral evaluation 
provided on June 25, 2020, by an OON provider. 
 
You asked the Plan to pay for the bitewings, prophylaxis, and periodic oral evaluation. You say that the 
provider's office told you that the provider was in-network with your plan. The Plan denied your request. The 
Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available 
for procedures performed by OON providers. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
bitewings, prophylaxis, and periodic oral evaluation provided on June 25, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services to be provided by an out 
of network (OON) facility. 
 
You asked the Plan to pre-approve inpatient mental health services to be provided by an OON facility. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network facilities that 
are able to provide these services. Therefore, coverage criteria has not been met. 
 
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 
inpatient mental health services to be provided by an out of network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injection, lumbar, sacral (64493). 
 
You asked the Plan to pre-approve facet injection. You say that you are requesting a fast appeal. Please see 
clinical. The Plan denied your request. The Plan says based on the records received the requested service 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 facet injection. Our reviewer says that 
 
 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the member is noted to have a history of low back pain. More specifically she has a 
history of right sided radiculopathy and has undergone ESIs at L4-L5 for this indication. According to the 
applicable LCD, in order for a facet joint injection to be covered it must not be associated with radiculopathy.  
Furthermore, per the LCD, there must be documentation that the "Clinical assessment implicates the facet joint 
as the putative source of pain". In this case the most recent office visit note from 9/17/20 did not indicate that 
there was a source of pain or tenderness at L4-L5. Rather the only tenderness was localized to L5-S1. 
Consequently, it cannot be said that the requirements of the LCD for coverage of this service have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injection, lumbar, sacral (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup. 
 
You asked the Plan to pre-approve the dental services. You say that you need a crown, and it cannot be 
completed without the core buildup. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for removal of forehead wrinkles (15824). 
 
You asked the Plan to hold you harmless for removal of forehead wrinkles. You say that the services rendered 
were medically necessary. The Plan denied your request. The Plan says that the service rendered was a non-
covered service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for removal of forehead wrinkles by a contract provider. The file does not show that the Plan 
provided notice that removal of forehead wrinkles would not be covered. Under Medicare rules, this means 
removal of forehead wrinkles is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for removal of forehead wrinkles (15824).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a nebulizer with compressor provided on December 28, 
2019. 
 
You asked the Plan to pay for nebulizer. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this item is correct, because the documentation submitted does 
not include a valid item for the item billed on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the delivery date for DME must be within 3 
months of the initial date of the CMN or DIF or the physician?s signature on an order.  
 
We looked at the file and Medicare rules. The referral form submitted is dated June 28, 2017, which is more 
than 3 months prior to the date of service billed and is therefore not a valid order for this date of service. Based 
on this information, we decided that Medicare rules for coverage of nebulizer have not been met. Therefore, we 
decided that the Plan does not have to pay for a nebulizer with compressor provided on December 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ALS emergency ambulance service (A0427) and ground 
mileage (A0425) provided March 16, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that this claim is for emergency ambulance 
transport. Please review this denial, the attached medical records and reprocess this claim. The Plan denied 
your request. The Plan says this service was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, you provided ambulance service to while the enrollee was inpatient in the hospital facility. Medical 
items, supplies and services provided to inpatients are covered under Part A. Payment for this service would 
have been included under the facility claim for the inpatient services. records show that the enrollee was 
inpatient March 7, 2020 to March 25, 2020. Therefore, the plan is not required to pay you separately for this 
claim. 
  
Therefore, we decided that the Plan does not have to pay for ALS emergency ambulance service (A0427) and 
ground mileage (A0425) provided March 16, 2020.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage 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 review indicates that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving care. 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on May 28, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you are unable to pay for 
these services. The Plan denied your request. The Plan says the benefits for this service have been satisfied and 
the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and an 
additional intraoral periapical x-ray on May 28, 2020. The Plan covered the first intraoral periapical x-ray, and 
your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the additional intraoral periapical x-ray provided on May 28, 2020.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. The Plan says that the care needed can be provided in the current inpatient hospital. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and her needs are being met in the current acute 
setting. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. 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 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 the critical care services rendered on April 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care services rendered on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the PPE (D1999) provided on June 3, 2020. 
 
You asked the Plan to pay for the PPE. You say that you should be reimbursed for this PPE charge because 
your plan reimburses members for this charge if they pay out of pocket. The Plan denied your request. The Plan 
says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the PPE 
(D1999) provided on June 3, 2020.