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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on August 21, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would like this claim to be reviewed and processed towards payment. The Plan denied your request. The 
Plan says non-emergency ambulance transportation is covered when it is the only way to safely and adequately 
transport an enrollee, or if other means of transportation are unsafe due to a medical condition. The Plan also 
says this claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the hospital to the 
enrollees assisted living facility was not medically necessary. Our physician reviewer found the enrollee did 
not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollees condition. Our reviewer also found that a prudent 
layperson would not believe that immediate medical attention was required for someone who was being 
discharged from the hospital to an assisted living 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 the non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on August 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210), 
2D oral/facial photographic image obtained intra-orally or extra-orally (D0350 x4), and cone beam CT capture 
and interpretation with field of view of both jaws (D0367).  
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the denial is 
correct, because these services are not covered by the Plans dental benefits or they are covered but the 
coverage benefit has been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the intraoral - complete series of radiographic images (D0210), was exhausted on date 
of service July 30, 2020. Therefore, we decided that the Plan does not have to pay for intraoral - complete 
series of radiographic images (D0210), 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350 x4), and cone beam CT capture and interpretation with field of view of both jaws (D0367). The Plans 
dental benefits do not include coverage for the oral/facial photographic image obtained intra-orally (D0350) 
and the cone beam CT capture and interpretation (D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
neurologist. 
 
You asked the Plan to pre-approve the physician services. You say that the enrollee has been managed by a 
provider at the requested provider's office. You say that the enrollee's condition is worsening. You also say that 
having to start over with a new provider is unfair and unsafe given the enrollee's rapid decomposition. The Plan 
denied your request. The Plan says the requested services are 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an out-of-network (OON) neurologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral cryoablation of the posterior nasal nerves/ 
ClariFixTM Cryotherapy (CPT code 30999). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary due to lack of sufficient peer-reviewed 
evidence of its efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the medical necessity of the requested service for the 
enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral cryoablation of the posterior nasal nerves/ ClariFixTM Cryotherapy (CPT code 
30999).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you do not agree with the claim denial. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 enrollee is medically stable and does not need PM&R physician's close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. At the current functional level, the enrollee does not need 3 hours a day x 5 days 
a week of therapies with multidisciplinary approach in an IRF. The enrollee has no medical acuity or 
complexity and no acute rehab nursing needs for an IRF admission. The enrollee's rehab needs can be safely 
met in an alternate and low intensity setting such as in a skilled nursing 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lexiscan stress test (78452) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a stress test. You say that you have been working on your contract with the 
plan. You disagree with the denial and would like an overturn decision so you can continue to see the enrollee. 
The Plan denied your request. The Plan says the enrollee must receive care from a network provider. The 
requested non-emergent service is available and can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Lexiscan stress test (78452) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee can receive care in another setting such as a skilled nursing facility, outpatient setting or home health 
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 in the Medicare rules section. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266), bone replacement graft for ridge preservation-per site (D7953) and fixed partial denture sectioning 
(D9120) provided on January 11, 2022. 
 
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft and fixed partial denture 
sectioning. You say that you would like these services covered. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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 guided tissue regeneration - resorbable barrier, per site (D4266), bone replacement graft for ridge preservation-
per site (D7953) and fixed partial denture sectioning (D9120) provided on January 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan. 
 
You asked the Plan to pre-approve Rocklatan. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Rocklatan.  
 Benefits for Rocklatan may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve a lntracept Procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered 
by Medicare or the Plan. 
 
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 a lntracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. More research is needed 
due to insufficient evidence of efficacy. 
 
 
 
 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 lntracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee has complex functional impairments (neurologic 
weakness, IRF compliant diagnosis). Clinical documentation shows that the enrollee has multiple active issues 
including thrombocytopenia, leukocytosis (with hx of CML-thus active comorbidity) and complicated wound 
issues. Evaluating therapists recommend ongoing therapy in an intensive, multi-disciplinary setting thus the 
enrollee would be expected to require continued inpatient hospitalization during rehabilitation. IRF criteria is 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the at home COVID-19 test kits purchased on July 31, 2022. 
 
You asked the Plan to pay for the at home COVID-19 test kits. You say that you would like to be reimbursed 
the correct amount for the COVID-19 test kits. The Plan denied your request. The Plan says that the additional 
sum of $36.00 exceeds the Federal reimbursement threshold, and is not a covered benefit. 
 
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. We find that the enrollee received under the monthly threshold, and the Plan has 
not forwarded any reason why the tests should not be covered in full, as the tests were purchased after the 
Federal guidance went into effect. The documentation does not provide any maximum monetary value that is 
able to be reimbursed to the enrollee for COVID-19 tests, nor does it show that the enrollee met the maximum 
allowed of 8 tests having been reimbursed. Therefore, we decided that the Plan has to pay for the at home 
COVID-19 test kits purchased on July 31, 2022.  
 
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 pre-approve an Intracept Procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are 
not covered by Medicare or the Plan. 
 
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 an Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. More research is needed 
due to insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on June 3, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says the information provided does not support ambulance transport to or from a 
physician's office, clinic, or outpatient clinic, which are not covered destinations. The Plan also says there was 
no documented acute, urgent, or emergent condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 
 
 
 
 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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance was not medically 
necessary. Our physician reviewer found the enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van) without endangering the enrollees condition. 
Our reviewer also found that a prudent layperson would not believe that immediate medical attention was 
required or someone who was attending scheduled appointments. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on June 3, 2022.