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

 
We decided that the Plan has to pay for amputation, foot; transmetatarsal (28805) provided April 13, 2020. 
 
You asked the Plan to pay for the amputation. You say that the records provided should support the necessity 
of the services in dispute. The Plan denied your request. The Plan says that the documentation does not meet 
requirements for billing modifier 22. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -22 modifier if the 
service billed with the modifier indicates an increase procedural service. 
 
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 amputation. Our reviewer says that the 
documentation does meet the criteria for billing 22 modifier. Our physician reviewer found the amputation, 
foot transmetatarsal (with increased procedural services modifier 22) billed to the health plan for services 
provided meets criteria for billing or reimbursement consideration regarding Modifier 22. In order to use 
Modifier 22, the physician must note in the medical documentation details that support the additional work and 
extra payment (e.g., increased intensity, time, technical difficulty of procedure, severity of patient's condition, 
physical and mental effort required). The submitted documentation does adequately support the increased 
difficulty involved in performing procedure 28805 22, and is eligible for reimbursement. 
 
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 amputation have been met. Therefore, we decided that the Plan has to pay 
for amputation, foot; transmetatarsal (28805) provided April 13, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fully electric hospital bed. 
 
You asked the Plan to pre-approve the fully electric hospital bed. You say that you are bed bound, cannot eat 
well, and are blind. You say that you have dementia, urinary incontinence, and Parkinson's disease. You say 
that hospice removed the bed you had once hospice services ended. You say that you do not have a bed at the 
time being and are in need of one. The Plan denied your request. The Plan says fully electric hospital beds are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully electric 
hospital bed.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for 2 periapical x-rays. We decided that the Plan does not have to pay for 
the additional periapical x-ray.  
 
You asked the Plan to pay for 2 periapical x-rays. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says that 2 of D0220, D0230, D0270, D0272, D0273 or D0274 per 1 calendar 
year are covered. The Plan says that the benefit for these services has been exhausted as of May 21, 2019. 
  
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. 
 
We decided that the Plan has to pay for 2 periapical x-rays.  
 
The Evidence of Coverage says that 2 bitewing or periapical x-rays are covered per calendar year. The Plan has 
not substantiated that 2 of these x-rays have been paid in 2020. Therefore, we decided that the Plan has to pay 
for 2 periapical x-rays. 
 
We also decided that the Plan does not have to pay for the additional periapical x-ray. 
 
The frequency limit of 2 periapical or bitewing x-rays per calendar year has been exceeded. Once the Plan 
processes the payment for the 2 periapical x-rays that were overturned in this case, the benefit will have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stem cell injection for the knees. 
 
You asked the Plan to pre-approve the requested stem cell injections. You say that this is shown to be helpful 
and should be covered. The Plan denied your request. The Plan says current evidence does not support the 
safety and efficacy of this procedure. 
 
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 requested stem cell injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee presents with complaints of worsening chronic bilateral knee 
pain. Clinical exam findings are reported consistent with radiographic evidence of severe bilateral 
patellofemoral and moderate left medial tibiofemoral osteoarthrosis. Prior cortisone injections reportedly were 
of benefit. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol 
trial and failure has not been submitted. Under consideration is a request for stem cell injections for the knees. 
Current evidence based medical peer reviewed literature indicate that stem cell therapy remains investigational 
for the treatment of knee osteoarthritis. Therefore, the request for stem cell stem cell injections for the knees 
would not be considered medically reasonable and necessary at this time as the safety and effectiveness has not 
been fully established. 
 
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 requested stem cell injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve stem cell injection for the knees.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of your 
arm (73221) provided on August 21, 2020. 
 
You asked the Plan to waive the copayment for the MRI of your arm. You say that the copayment amount is 
too high. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 an MRI.  
 
You have been asked to pay a $150 copayment for the MRI of your arm. The MRI of your arm falls within the 
advanced imaging 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 magnetic resonance 
imaging (MRI) of your arm (73221) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 29, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 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 a domiciliary, rest home visit provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diagnostic services rendered on 
September 15, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was 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 a 20% 
coinsurance for in-network diagnostic procedures and tests at an outpatient hospital.  
 
Review of the file shows that you received diagnostic services on September 15, 2020. You have been asked to 
pay a 20% coinsurance for these services. These services fall within the in-network diagnostic procedures and 
tests at an outpatient hospital 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 
diagnostic services rendered on September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Avonex Pen. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an Avonex Pen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Synvisc-One. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our physician reviewer 
found that the enrollee has a history of osteoarthritis of the right knee. The clinical diagnosis is supported by 
radiologic evidence of osteoarthritis of the knee. Other diagnoses have been excluded. The enrollee has failed 
at least three months of conservative therapy. The Plan requires a trial of Synvisc-One before they will approve 
the requested drug. The enrollee has not tried and failed the required drug.  The plan?s required drug is not 
likely be less effective, or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval of IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 treatment of a stroke. The enrollee's medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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 documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
You asked the Plan to pre-approve additional routine transportation trips. You say that the member has medical 
conditions that require frequent office visits and need transportation coverage. The Plan denied your request. 
The Plan says the member has used a total of one-hundred eight (108) trips, exhausting their benefit. 
 
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. 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. The 109th 
trip and beyond is not a covered benefit. The member's 2020 EOC states, "the Plan covers up to sixty (60) one-
way trips each calendar year to and from locations within the local service area (60-mile limit per one-way trip) 
when obtaining plan covered services" and "this plan offers coverage for forty-eight (48), one-way, routine 
transportation services every year. Trips are limited to 60 miles." Furthermore, as the year has changed since 
the appeal began, please check the member's 2021 EOC for coverage rules regarding routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided, the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does not require an intensive inpatient rehabilitation therapy 
program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care in the home with home health services or in a skilled 
nursing facility appears to be more appropriate in this case.    
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to change the copayment for surgery services provided on September 2, 
2020. 
 
You asked the Plan to change the copayment for the facet joint injection (64633). You say that there should 
only be a physician specialist office visit copayment. The Plan denied your request. The Plan says you were 
charged this copayment 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 $500 
copayment for Outpatient Surgery at hospital facility.  
 
You have been asked to pay a $500 copayment for the facet joint injection (64633). The facet joint injection 
(64633) falls within the Outpatient Surgery at hospital facility benefit category. The record shows the surgical 
procedure was done at a pain treatment center. 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 change the copayment for surgery 
services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade injection (100mg) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a request for a Part D drug, and there is no pharmacy benefit with this plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Remicade injection 
(100mg) for the enrollee.
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 will benefit from aggressive rehab in 
order to return home. The Plan denied your request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 COVID 19 pneumonia and a urinary tract infection. The enrollee's medical conditions are 
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. 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 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that radiofrequency ablation of the genicular 
nerves will improve the enrollee's function and quality of life. The Plan denied your request. The Plan says the 
service is still being studied for efficacy in the treatment of knee pain due to osteoarthritis. 
 
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 requested services. Our physician 
reviewer found that the enrollee continues to have pain in both knees. Genicular nerve blocks and genicular 
nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee 
pain. The review has determined that the requested genicular nerve radiofrequency ablation is not safe and 
effective to treat the enrollee's condition. The requested treatment is not medically reasonable or necessary for 
the enrollee's 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation.