Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001, 77014) 
also known as US-IGRT. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that this is a non-invasive, 
highly recommend treatment modality for this enrollee due to the location of each lesion, current enrollee 
comorbidities and current medications. Course of treatment is medically necessary. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280- also requested 
in this case) and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general) 
is not necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001, 77014) also known as 
US-IGRT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit with an electrocardiogram (EKG) provided on 
February 08, 2022. 
 
You asked the Plan to pay for an office visit with an electrocardiogram (EKG). You say that this was medically 
necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit with an 
electrocardiogram (EKG) provided on February 08, 2022.
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 services are necessary to restore the enrollee's 
independence in activities of daily living, transfers and ambulation with an assisted device. The Plan denied 
your request. The Plan says the services the enrollee needs can be provided safely in another setting such as, a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. The Plan also says that the provider 
documents only a need for 24 hours of observation care (or 1 midnight for this planned outpatient peripheral 
orthopedic procedure). 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found at the time of inpatient admission, the admitting physician reasonably 
expected that the patients necessary hospital care (including earlier Emergency Department and/or observation 
care) would span two midnights. Our physician reviewer also found the record does not show that at the time of 
inpatient admission, the admitting physician reasonable expected that the patient's necessary hospital care 
(including earlier emergency department and/observation care) would span two midnights, and the enrollee 
does not meet the criteria for inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 strict monitoring as 
well as physical therapy, occupational therapy, and speech therapy. The Plan denied your request. The Plan 
says the LTACH is not medically necessary, and the enrollee's needs are being met in the current inpatient 
hospital. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he/she is currently receiving 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided by an out-of-network provider on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have seen this provider previously and you 
did not know they were out-of-network. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. Also, the enrollee 
was assigned to an in-network provider prior to the date of service. 
 
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. 
 
  The record shows you received the requested 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 pay for a periodic oral evaluation (D0120) and a cleaning (D1110) provided by an out-of-network provider 
on October 27, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve the HBOT (CPT code(s): 99183 and G0277). 
 
You asked the Plan to pre-approve the HBOT. You say that this will assist the enrollee's wound to heal. The 
Plan denied your request. The Plan says that there is no evidence of failure of healing with standard wound 
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 HBOT. Our physician reviewer 
found per clinical standards and NCD 20.29 as hyperbaric oxygen therapy is standard treatment for a 
radionecrosis wound. 
 
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 HBOT have been met. Therefore, we decided that the Plan has to pre-
approve the HBOT (CPT code(s): 99183 and G0277).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the guided tissue regeneration (D4266), an extraction 
(D7210), and a bone replacement graft (D7953) for tooth #10 provided on July 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the procedures should be processed under 
your medical benefits. The Plan denied your request. The Plan says your annual dental benefit for the year has 
already 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. On June 13, 
2022, the Plan paid $70.40 for dental services. On July 5, 2022, the Plan paid $929.60 for dental services. For 
the year of 2022 the Plan paid a total of $1,000 ($70.40 paid + $929.60 paid) for dental services. Therefore, 
record shows your annual dental benefit for the year was exhausted on date of service July 5, 2022. Therefore, 
we decided that the Plan does not have to pay more for the guided tissue regeneration (D4266), an extraction 
(D7210), and a bone replacement graft (D7953) for tooth #10 provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on August 
08, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a subsequent nursing 
facility care visit provided on August 08, 2022.
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 services are necessary for a safe and 
sustainable discharge for the enrollee. The Plan denied your request. The Plan says the enrollee can remain in 
the current acute care location until such time no further acute level care is needed. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination commode/shower chair. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. The rules also say that a commode chair is covered only for enrollees who are 
confined to a bed or a room. 
 
While a commode/shower chair may be appropriate in this case, you do not meet criteria for coverage of the 
requested item. Specifically, shower chairs are not a covered benefit by the Plan or by Medicare. Additionally, 
the rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file 
does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that 
the Plan does not have to pre-approve a combination commode/shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit, including medical vision 
services and extracapsular cataract removal provided on June 30, 2022, to October 6, 2022. 
 
You asked the Plan to waive the copayment for office visit, including medical vision services. You say that the 
charges that you have been charged are excessive and overcharged. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for an OON (out-of-network) services provided on June 30, 2022, and July 19, 2022. A $45 
copayment for an INN (in-network) services provided on August 25, 2022, September 1, 2022, and October 6, 
2022. Also, a 40% coinsurance for an OON (out-of-network) services provided on August 22, 2022. for 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, and physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $50 copayment for OON services provided on June 30, 2022, and July 19, 2022. 
A $45 copayment for INN services provided on August 25, 2022, September 1, 2022, and October 6, 2022. 
Also, a 40% coinsurance for OON services provided on August 22, 2022. for office visit, including medical 
vision services.  
 
 
This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers, and physician/Practitioner services, including doctor's office visits. 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 an office visit, including medical vision 
services and extracapsular cataract removal provided on June 30, 2022, to October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat endoscopic rhizotomy services. 
 
You asked the Plan to pre-approve repeat endoscopic rhizotomy services. You say that the requested surgery is 
needed to relieve some of your pain. You say that you had this surgery done before and it helped for a long 
while. The Plan denied your request. The Plan says the requested procedure has not been shown to be safer or 
more effective than thermal radiofrequency ablation (RFA) services. 
 
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 repeat endoscopic rhizotomy services. 
Our reviewer says that the requested endoscopic rhizotomy services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat endoscopic rhizotomy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat endoscopic rhizotomy services.
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 is stable and ready to be admitted to an 
IRF. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollees needs can be met at a lower level of 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is a treatment 
gap for patients who do not receive adequate relief from traditional conservative methods and who don't have 
instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says the 
requested procedure is 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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.