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

 
We decided that the Plan does not have to pay for the tenotomy procedure (CPT 24310) provided to the 
enrollee on April 26, 2018. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is a duplicate of the same procedure billed by the same provider. 
 
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 24310 is "tenotomy, open, elbow to shoulder, each 
tendon." 
 
We asked our coding 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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
provider was reimbursed on claim number 000420011738809 check date September 9, 2016. The 
documentation submitted did not include a "redacted" claim.  Therefore, the second claim submitted would be a 
duplicate. 
 
We looked at this coder'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 the tenotomy procedure (CPT 24310) provided to the enrollee on April 26, 2018.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve paravertebral facet joint destruction for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the medical records do not show that the provider confirmed facet joint pain by 
noting that dual medial branch blocks provided at least 80% pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA may be repeated if there was 50% or more 
improvement in pain for at least six 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had fifteen months of pain relief from the prior RFA, and the request is to repeat it. 
This is consistent with the LCD, and there is no need to repeat a diagnostic medial branch block. The request is 
medically reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve paravertebral facet joint destruction for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction services provided on July 7, 2020. 
 
You asked the Plan to pay for refraction services. You say that these services should be covered by the Plan. 
The Plan denied your request. The Plan says refraction services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. Medicare does not cover refraction 
services. The Plan does not cover refraction services. Therefore, we decided that the Plan does not have to pay 
for refraction services provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider at your in-network benefit level. 
 
You asked the Plan to pre-approve the medical services. You say that the provider you wish to see at the clinic 
has experience and is highly regarded in the oncology urology field of medicine. You says that you need to see 
a doctor who has expertise and superior knowledge in this field. The Plan denied your request. The Plan says 
that the medical need for the enrollee to go to this out of network facility is not supported. The Plan says that 
the enrollee can receive care for his medical condition from a urologist in network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 medical services. Our physician reviewer found the Plan?s denial is 
medically justified on the basis that it is offering adequate care to meet your medical needs through referral to a 
non-tertiary in-network urologist. There is nothing unique about your condition that would make it medically 
necessary for you to see the requested out-of-network tertiary level provider. The plan has shown that they 
have in-network providers who meet the Standards of Care required for treatment of your 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 medical services have not been met. 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 the medical services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network provider at your in-network benefit level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital services (99223) provided on May 20, 
2020. 
 
You asked the Plan to pay for the initial hospital services. You say that you would like reconsideration because 
these were distinct, separately identifiable, medically necessary services. The Plan denied your request. The 
Plan says initial hospital care codes may only be reported once per day by the same physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that if more than one evaluation and management service is provided on the same day to the 
same patient by the same physician, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. 
 
We find that CPT code 99223 is not supported in the record. Specifically, the record indicates that an 
evaluation and management service rendered to this member has previously been processed and paid for the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of the initial 
 
 
hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the initial 
hospital services (99223) provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physician services (99345, 99497, G0181, 99354) to 
be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you want the home physician visits to 
avoid traveling to office visits during the ongoing pandemic. The Plan denied your request. The Plan says the 
services are not considered emergent. There are in-network providers that can provide the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
physician services (99345, 99497, G0181, 99354) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stand aid power raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that with this assisted seat you would be able to 
transfer to the toilet and back to your wheelchair while maintaining decency and privacy. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a stand aid power raised toilet seat.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member did not require any skilled nursing 
or rehab services on a daily basis at an inpatient level of care. The member did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the member did not require any 
skilled services on an inpatient basis, at a SNF level of care at the time of admission to the facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 20, 2020 by an OON 
provider. 
 
You asked the Plan to pay for an evaluation of a heart and blood vessel monitor system. You say that this 
service was necessary. The Plan denied your request. The Plan says rules for payment have 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 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 has network providers 
available who can provide 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 medical services provided on April 20, 2020 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abutment supported porcelain/ceramic crown, tooth 30 
(D6058). 
 
You asked the Plan to pre-approve the dental services. You say that the authorization has been denied for 
unsuspected preventive procedure you have been paying your dental but are not able to use your benefits. The 
Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
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. Services not listed is not 
covered by the plan. 
 
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 
Abutment supported porcelain/ceramic crown, tooth 30 (D6058).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of temporomandibular joint (TMJ) (20553) 
provided from May 13, 2019 to March 26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for treatment of TMJ by an OON provider. You say that the services are necessary. 
The Plan denied your request. The Plan says there are in-network providers 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 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 has network providers 
available who can provide 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 treatment of temporomandibular joint (TMJ) 
(20553) provided from May 13, 2019 to March 26, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of an interspinous distraction device services 
provided on May 20, 2020. 
 
You asked the Plan to pay for insertion of an interspinous distraction device services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 pay for insertion of an interspinous distraction 
device services. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has chronic neck, thoracic and lumbar 
back pain. The enrollee had a prior compression of a thoracic vertebra. The enrollee has multiple levels of 
degenerative disc disease and spinal stenosis. The services provided are considered experimental/ 
investigational. The procedure is not part of an established clinical practice guideline or algorthm. Therefore, 
the enrollee did not meet criteria for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an interspinous distraction device services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for insertion of an interspinous distraction device 
services provided on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the external defibrillator provided on April 
3, 2020. 
 
You asked the Plan to waive the coinsurance for the external defibrillator. You say that you were not informed 
about charges so you assumed the cost would be covered. You say that the cost is more than you can pay. The 
Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare-covered benefits from an in-network provider.  
 
You have been asked to pay $540.99, which is 20% of the allowed amount for the external defibrillator. The 
allowed amount is $2,704.94 (20% x $2,704.94 = $540.99). The external defibrillator falls within the "Durable 
Medical Equipment (DME) and Related Supplies" 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 
coinsurance for the external defibrillator provided on April 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation provided to the enrollee from June 
17, 2020 to July 2, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization which is required by the Plan contract 
and is the responsibility of the provider. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract specifically 
states prior authorization is required for outpatient rehabilitation services.  The Plan did not pre-approve the 
item/service at issue. Therefore, we decided that the Plan does not have to pay for outpatient rehabilitation 
provided to the enrollee from June 17, 2020 to July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 18. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has been experiencing severe 
pain. You say that the enrollee has open margins and recurrent decay. You also say that the current crown was 
placed over 10 years ago. The Plan denied your request. The Plan says core build up is not a covered service. 
 
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 core 
build up (D2950) for tooth # 18.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance transport. 
 
You asked the Plan to pre-approve the transport. The Plan denied your request. The Plan says air 
ambulance services are not covered for transport to a facility that is not an acute care hospital. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the 
destination is an acute care hospital.  
 
Air ambulance cannot be covered to a home. Based on this information, we decided that Medicare rules for 
coverage of the transport have not been met. Therefore, we decided that the Plan does not have to pre-approve 
air ambulance transport.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection (J7323). 
 
You asked the Plan to pre-approve a Euflexxa injection. You say that the enrollee had received aspiration and 
drainage of right knee in November 2020. You say that the enrollee has reported there has been no relief with a 
Cortisone injection and the pain is gradually increasing. You also say that the enrollee has tried Aleve, but is 
not supposed to take this medication due to stomach ulcers. The Plan denied your request. The Plan says no 
clear evidence of right knee osteoarthritis was provided. The Plan says knee injections are not medically 
necessary. The Plan also says that the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 a Euflexxa injection. Our reviewer says 
that the requested drug is not medically necessary. Our physician reviewer found the provided medical records 
do not show radiographic evidence of severe knee osteoarthritis. The reviewer also found that recent literature 
does not support the role of viscosupplementation in the treatment of knee pain. Therefore, the reviewer found 
that the requested Euflexxa injection is 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 a Euflexxa injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Euflexxa injection (J7323).