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

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 6, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic 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. 
 
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 hospital outpatient clinic visit provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the overdenture (D5860) and the precision attachments 
(D5862 x 2) provided on June 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were denied for no reason. You say 
that you have not made any claims for the last 5 years. You also say that they are on the list of dental programs. 
The Plan denied your request. The Plan says overdenture is not listed as a covered service. The Plan says 
precision attachments are not listed as a covered service either. 
 
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 
overdenture (D5860) and the precision attachments (D5862 x 2) provided on June 26, 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 enrollee requires ongoing acute care 
for his complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs are 
being met in the current acute setting. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with hypoxic respiratory failure 
secondary to pneumonia due to Covid-19. The enrollee was slowly improving; he reported chest pain, and there 
were new EKG changes. The enrollee was on high-flow oxygen via nasal cannula. LTACHs are certified as 
acute care hospitals, and in general, do not provide clinical services that are materially different than those of 
short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not 
been denied. 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 he is currently receiving care. The documentation does 
not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health stay provided from July 1, 2020, 
to July 3, 2020. 
 
You asked the Plan to pay for the inpatient mental health stay. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says medical criteria supporting an inpatient 
mental health stay have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health stay. Our 
reviewer says that the services provided were not medically necessary. Our physician reviewer found based 
upon review the records provided it was not expected this enrollee would improve in a reasonable period of 
time as she did not have dangerousness to self or others, auditory or visual hallucinations or behaviors 
threatening acute safety.  
 
It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care as she did not have dangerousness to self or others. 
 
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 inpatient mental health stay have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient mental health stay provided from July 1, 2020, to July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from February 5, 2020, through 
April 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
physician's services. 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 physician's services provided from February 5, 2020, through 
April 8, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to prep-approve a Zilretta injection. 
 
You asked the Plan to prep-approve Zilretta. The Plan denied your request. The Plan says that the safety and 
efficacy of repeat administration has not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 prep-approve Zilretta. Our physician reviewer found 
that the enrollee has chronic right knee pain due to primary osteoarthritis. Zilretta is indicated as an intra-
articular injection for the management of osteoarthritis pain of the knee. Based on the drug label, it does not 
preclude use of the drug more than one time. Drugs or biologicals approved for marketing by the Food and 
Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for 
indications specified on the labeling. Therefore, the documentation supports that Zilretta is medically 
reasonable and necessary, safe and effective 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 Zilretta have been met. Therefore, we decided that the Plan has to prep-approve 
a Zilretta injection.  
 
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 Vertiflex interspinous decompression device. 
 
You asked the Plan to pre-approve Vertiflex interspinous decompression device. You say that you would like 
the plan to reconsider their denial. 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 Vertiflex interspinous decompression 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have lumbar spinal stenosis with neurogenic 
claudication. The requested device is experimental. More research is needed to show safety and efficacy of the 
device. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex interspinous decompression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex interspinous decompression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 6, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s services. 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 physician's services provided on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 27, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were 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. 
 
We find that the laboratory services are not supported in the medical record. Specifically, these services should 
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on May 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 10 units of CPT 11046 provided on February 13, 2020. 
 
You asked the Plan to pay for 10 units. The Plan denied your request. The Plan says only 6 units of this code 
are supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 10 units Our reviewer says that the records 
provided do not support 10 units of CPT 11046. Our coding reviewer found that the operative report documents 
wound 15 cm x 8 cm x 2 cm = 120 sq cm = 6 units. The documentation does not support an additional 4 units. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 units have not been met. Therefore, we decided that the Plan does not have 
to pay for 10 units of CPT 11046 provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from May 11, 2020, through 
July 27, 2020. 
 
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
acupuncture services. 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 acupuncture services provided from May 11, 2020, through 
July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies provided on May 26, 2020, to June 8, 
2020 by an out of network provider. 
 
You asked the Plan to pay for the infusion supplies. You say that the infusion pump is medically necessary. 
The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 infusion supplies provided on May 26, 2020, 
to June 8, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast 
material (CPT Code 70551). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found 
based on the medical records provided there is no documentation that an MRI of the brain is medically 
reasonable and necessary. The provided medical note of November 19, 2020, provides no detailed description 
of the nightmare disorder other than reporting nightly disturbing nightmares. The neurologic review of systems 
and the neurologic examination detail no abnormalities. The note contains no assessment or plan or differential 
diagnosis which would justify the MRI scan. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, brain (including brain stem); without contrast material (CPT Code 70551).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 6, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s services. 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 physician's services provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 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 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 medical services provided to the enrollee by an out-of-network provider 
on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 15, 
2018. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration 
because the claim should not have been sent to review in February 2019 and you were given incorrect 
information. The Plan denied your request. The Plan says the claim was not submitted withing 365 days if the 
date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent hospital care was not filed until June 2, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction testing (95908, 95955) performed April 7, 
2020. 
 
You asked the Plan to pay for the nerve conduction testing. You say that the nerve conduction testing was 
medically necessary. The Plan denied your request. The Plan says the documentation does not support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95908, 95955 are not supported in the medical record. Specifically, the documentation 
does not include enough information to confirm that 3-4 nerve conduction studies were performed to support 
CPT 95908. The documentation does not include enough information to confirm that an EEG was performed to 
support CPT 95955. Based on this information, we decided that Medicare rules for coverage of the nerve 
conduction testing have not been met. Therefore, we decided that the Plan does not have to pay for nerve 
conduction testing (95908, 95955) performed April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on June 30, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you are entitled to be reimbursed for 
the teeth cleaning, oral examination, and x-rays. 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 Plans 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 
periodontal maintenance provided on June 30, 2020.