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

 
We decided that the Plan does not have to pre-approve peripheral nerve destruction (CPT Code 64624). 
 
You asked the Plan to pre-approve the services. You say that you have been getting the injection and they have 
been helping. The Plan denied your request. The Plan says the services are considered 
experimental/investigational and are not covered by Medicare. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
these procedures for you. Exceptional indications were not evident within this record. Therefore, the request for 
genicular nerve radiofrequency ablation (RFA), left knee, is not 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve destruction (CPT Code 64624).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) report and interpretation on 
July 24, 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 93010 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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of 
an EKG interpretation by the rendering provider. 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 
electrocardiogram (EKG) report and interpretation on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), 
periodontal maintenance (D4910), and the crown (D2740) provided from July 13, 2020, to July 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are retired and on a very limited fixed 
income. You say that after paying off your first financial agreement with the dental office, you were under the 
impression that you were clear of any further obligations. You also say that you feel the remaining amount 
should be discounted based on the quoted amount. The Plan denied your request. The Plan says there is an 
annual allowance of $500. The Plan says that the annual allowance has been exhausted. The Plan also says that 
you are responsible for any amount above the dental coverage limit. 
 
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 annual allowance of $500 for 
covered dental services has been exhausted. 
 
Date of Service Billed Amount Amount Reimbursed 
6/15/2020 $198 $198 
6/29/2020 $275 $275 
7/20/2020 $27 $27 
TOTAL:  $500 
 
 
 
 
 
 
 
 
 
 
The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage 
limit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish 
(D1206), periodontal maintenance (D4910), and the crown (D2740) provided from July 13, 2020, to July 20, 
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 10, 
2012 to August 8, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF 
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of 
coverage were not 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented 
skilled nursing and skilled therapy needs. The enrollee was at her functional baseline. Daily skilled services 
were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 
The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower 
level of care (ex. home, AL, LTC). 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided July 10, 2012 to August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
non-covered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on March 24, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that the referring provider is also out-of-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 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 durable medical equipment provided on March 24, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Home Visit telemedicine service provided on September 
1, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the Home Visit telemedicine service. You say that authorization should not be 
needed under telemedicine. 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 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 this service. Therefore, we decided that the 
Plan does not have to pay for the Home Visit telemedicine service provided on September 1, 2020, by an out-
of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheter supplies (A4326) provided from 
April 1, 2020, to July 6, 2020. 
 
You asked the Plan to waive the coinsurance for the catheter supplies. You say that the copayment was not 
charged in the past and it should be waived. The Plan denied your request. The Plan says the correct cost-
sharing 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 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay a 20% coinsurance for the catheter supplies. The catheter supplies fall within the 
Durable Medical Equipment 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 catheter 
supplies (A4326) provided from April 1, 2020, to July 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional five (5) physical therapy visits. 
 
You asked the Plan to pre-approve the additional five (5) physical therapy visits. The Plan denied your request. 
The Plan says an additional five (5) physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional five (5) physical therapy 
visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to 
prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy 
is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had 
extensive therapy for this condition and it does not appear that the enrollee's functional level requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has 
been instructed in an independent exercise program. The specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. 
 
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 additional five (5) physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional five (5) physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76942-59. We decided that the Plan does not have to pay for 37233.  
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan says that the 
services are not supported by the records. 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 
services.  
 
We decided that the Plan has to pay for 76942-59.  
 
Our physician reviewer found that is documented in the procedure note dated July 22, 2020: "The left common 
femoral artery was accessed under ultrasound guidance with a 21-gauge needle." The documentation supports 
that ultrasonic guidance was used for needle placement. Therefore, we decided that the Plan has to pay for 
76942-59.  
 
We also decided that the Plan does not have to pay for 37233. 
 
Our physician reviewer found that the documentation does not support that a balloon was inflated in order to 
dilate the tibial/peroneal vessels to a larger diameter. Therefore, we decided that the Plan does not have to pay 
for 37233. 
 
 
 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 29, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent. There were network providers available. 
 
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 lab services provided on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the Group 2 power wheelchair (PWC) provided on July 8, 2020. 
 
You asked the Plan to pay for the Group 2 PWC. You say that this should be paid as you provide PWCs for 
purchase and are allowed to do so. Also, you were not reimbursed the correct amount for E0990. The Plan 
denied your request. The Plan says that this case was processed untimely, and no review of the original denial 
was performed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. in this case, no valid denial rationale has been presented for the PWC. The 
remittance advice simply says that this is paid at the Medicare allowable rate; however, no payment at all was 
made for code K0823. Based on the appeal letter, it appears that the issue may be that this was provided as a 
purchase rather than rental, though, of note, there is nothing from the Plan which confirms this. Regardless, this 
is not a valid denial rationale because, as cited above, electric wheelchairs must be offered for purchase. No 
other justification for denial of payment was provided. Therefore, we decided that the Plan has to pay for the 
Group 2 power wheelchair (PWC) provided on July 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 6, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 August 6, 2020, 
by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says a skilled nursing facility would be a more appropriate treatment level. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
infection of artificial knee joint. You are treated with once daily ceftriaxone IV until 2/10/21. Weekly labs are 
requested by infectious disease specialist. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record 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 you will 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and related electronic 
connection to be provided with an approved power wheelchair (PWC). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that this is necessary for this 
enrollee in order to complete daily living activities. The Plan denied your request. The Plan says the PWC was 
approved; however, coverage is not allowed for the power seat elevator. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature.  
 
Although this feature may be appropriate, neither Medicare nor the Plan can provide coverage for this item. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and related 
electronic connection to be provided with an approved power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before alternatives can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drug or an osteoporosis related fracture. The record does not show any reason the plan preferred drug would be 
unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).