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

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve the ESI services. You say that the requested procedure is medically 
necessary. You say that the enrollee has failed conservative therapy, medications, physical therapy and 
chiropractic therapy. You say that the enrollee had the requested procedure previously and showed 80% pain 
relief. The Plan denied your request. The Plan says the enrollee has exhausted their benefit for epidural steroid 
injections. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI services are covered for certain medical 
indications, at a maximum of 4 sessions per spinal region in a rolling 12-month period.  
 
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 ESI services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
has had lumbar epidural steroid injections on August 13, 2021, April 20, 2022, May 18, 2022, and on July 14, 
2022. She has had 4 epidural steroid sessions per spinal region in a rolling 12-month period. In addition, the 
records do not document at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using same scale for at least three months between injections. The request exceeds 
utilization criteria and also there is a lack of documentation on the degree and duration of pain relief following 
each of these injections. 
 
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 ESI services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epidural steroid injection (ESI) 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 acute inpatient rehabilitation is being recommended 
for your recovery. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our 
reviewer found that you are functioning at a level commiserate with your bilateral, upper extremity, weight-
bearing restrictions. Our physician reviewer also found that your needs can be met at a lower level of care. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical shoulder arthroscopy with the InSpace balloon 
implant for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is still in need of stronger evidence to recommend routine use. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further/ongoing studies are needed for this 
implant. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception to guidelines. Therefore, the requested right shoulder arthroscopy with 
the InSpace balloon implant, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical shoulder arthroscopy with the InSpace balloon implant for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopy (43236) provided on October 15, 2021. 
  You asked the Plan to pay for the endoscopy (43236). You say that modifier 79 was added and CPT code 
43236 is separately payable. The Plan denied your request. The Plan says CPT code 99231 has been 
overturned. The Plan also says CPT 43236 is included in CPT code 43255 and cannot be separately 
reimbursed. 
 
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, we have confirmed that code 43236 is a column II code to column I code 43255; however, 43236 
was billed with a modifier.  
 
We asked our coder 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 endoscopy (43236). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not include enough documentation to confirm the post operative endoscopy was unrelated 
to the primary endoscopy service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the endoscopy (43236) have not been met. Therefore, we decided that the Plan 
does not have to pay for the endoscopy (43236) provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 test kits you purchased on December 23, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you believe these should be 
covered. The Plan denied your request. The Plan says there was no coverage for COVID-19 home test kits at 
the time you purchased these. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may cover at-home 
COVID-19 tests as a supplemental benefit starting January 15, 2022, or prior depending on the specific benefits 
offered by the Plan. In this case, your Plan did not offer coverage of these tests prior to February 1, 2022. There 
was no coverage for these tests available under your Plan on the date that you purchased these tests. Therefore, 
we decided that the Plan does not have to pay for at-home COVID-19 test kits you purchased on December 23, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint radiofrequency ablation provided to the 
enrollee on June 18, 2021. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. The current evidence suggests that sacral lateral 
branch radiofrequency ablation can provide relief for posterior sacroiliac joint complex pain. However, the 
literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, 
and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies. Further 
studies are needed. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested radiofrequency ablation used for 
sacroiliac pain performed on 6/18/21, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for sacroiliac joint radiofrequency ablation provided to the enrollee on June 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mRNA gene analysis of 31 genes in skin melanoma 
tissue specimen (81529) provided on April 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mRNA gene analysis of 31 genes in skin melanoma tissue specimen. You say 
that this test was ordered by the enrollee's physician. The Plan denied your request. The Plan says this service is 
not covered because it was provided OON. 
 
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 had network providers 
available who could have provided 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 mRNA gene analysis of 31 genes in skin 
melanoma tissue specimen (81529) provided on April 6, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 17, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 code 73100 is not supported in the medical record. Specifically, the enrollee was inpatient at 
a skilled nursing facility at this time, so the services should not be reported separately. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 1, 2022, to January 22, 2022. 
 You asked the Plan to pay for the SNF services. You say that the services which the enrollee required and 
received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 from January 1, 2022, to January 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections.  
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that A second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the diagnostic facet 
joint injections at C5-C7 on April 11, 2022 did not document a consistent positive response of at least 80% 
relief of primary (index) pain. The review has determined that the enrollee did not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network provider. You say that you were referred to the dentist by 
your previous dentist who is now retired. The Plan denied your request. The Plan says you do not have out-of-
network benefits. The Plan also says that there are several, nearby in-network providers. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment is made for laboratory 
services in this case. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on March 22, 
2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that this was a regular office visit 
and should only be charged $10 copayment. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
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 $40 
copayment for each individual or group therapy visit.  
 
You have been asked to pay $40 copayment for mental health visit. Mental health visits fall within the 
Outpatient Mental Health Care 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 
mental health visit provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the claim was processed incorrectly with the facility 
national provider identifier (NPI) and not the rendering provider as it should. The Plan denied your request. 
The Plan says care received from an out-of-network provider will not be covered, and there is no authorization 
on file. 
 
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 had network providers 
available who could have provided 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 an office visit provided on February 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305) provided on March 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the enrollee does not come to the lab, the specimen 
is sent by their participating doctor. The Plan denied your request. The Plan says the provider and referring 
physician in this case are 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 had network providers 
available who could have provided 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 lab services (88305) provided on March 22, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has had a complex hospital 
course but has been improving. The most recent documentation indicates a worsening chest x-ray. The enrollee 
will eventually need daily skilled care in short-term rehab; however, the documentation doesn't support that he 
is stable at this time for discharge from the hospital. He has continued parental antibiotics and wound care and 
will require skilled rehab services. Admission to a SNF for inpatient skilled rehab services is not medically 
appropriate as he does not appear medically stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.