Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of 
congestive heart failure, hypertensive heart disease, hypothyroidism, dementia, morbid obesity, pressure 
ulcerations and urinary incontinence and is living at home with weakness. There is no documentation of 
medical problems for which inpatient medical care is needed. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all endoskeletal lower extremity prosthesis, axial 
rotation unit, with or without adjustability (CPT code L5984) and all lower extremity prosthesis, shank foot 
system with vertical loading pylon (CPT code L5987). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says you have had leg amputations. The Plan states the prosthetic legs have already been 
approved for you and the records the Plan have do not show why the requested advanced feet are needed. The 
Plan states that there are other feet are available that can meet your needs. The Plan states a request for 
prosthetic feet that meet your needs and Medicare guidelines can be reviewed if submitted. 
 
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 items. Our physician reviewer 
found the documentation does not reveal that you are participating in high impact activities. The physician 
documentation does not support that you require an advanced K3 level foot, and the physician documentation 
does not indicate that your functional level cannot be safely and adequately met with a lesser level foot. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability 
(CPT code L5984) and all lower extremity prosthesis, shank foot system with vertical loading pylon (CPT code 
L5987).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care skilled nursing services provided from 
May 19, 2021, to June 5, 2021. 
 
You asked the Plan to pay for the custodial care skilled nursing services. The Plan denied your request. The 
Plan says custodial care is not covered because it is excluded by your healthcare plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care skilled nursing services have not been met. Specifically, we find that the services 
at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay 
for the custodial care skilled nursing services provided from May 19, 2021, to June 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services provided on October 
1, 2021, through December 17, 2021. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you would like 
reconsideration because the dialysis treatment is related to COVID-19 treatment. The Plan denied your request. 
The Plan says the claim processed in accordance with the EOC. 
 
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 Services to treat kidney disease.  
 
You have been asked to pay a 20% coinsurance for the dialysis services. The dialysis falls within the Services 
to treat kidney disease 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. Of note, per the Plan's Frequently Asked Questions regarding COVID-19, the waiver of 
out-of-pocket costs related to the treatment of COVID-19 ended as of September 30, 2021. As of October 1, 2021, coverage for COVID-19 treatment returned to your pre-pandemic standard benefit. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the dialysis services provided on October 1, 
2021, through December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided by a participating 
provider on December 10, 2021. 
 
You asked the Plan to pay for pulp vitality tests. You say that this claim should not be denied. The Plan denied 
your request. The Plan says this claim has been correctly processed and denied. 
 
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 pulp 
vitality tests (D0460) provided by a participating provider on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on April 12, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a staff member at the laboratory stated that all cardiovascular genetic kits are provided to member via mail and returned via mail. The provider did not write an order for the enrollee to undergo this testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular risk assessment testing provided to the enrollee on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity revascularization. 
 
You asked the Plan to pre-approve a lower extremity revascularization. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under specific 
circumstances. 
 
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 lower extremity revascularization. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found coverage criteria 
for a lower extremity revascularization including iliac artery angioplasty and stenting are not met. A careful 
review of the records does not demonstrate any complaints by the enrollee that would be addressed by iliac 
artery angioplasty and stenting. There is no documentation of absent femoral pulses and no documentation of 
lifestyle limiting claudication or rest pain. There is no provider encounter or assessment wherein iliac artery 
angioplasty and stenting is being considered or 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 a lower extremity revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lower extremity revascularization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a down sweater jacket purchased on December 6, 2021. 
 
You asked the Plan to pay for the down sweater jacket. You say that you would like reconsideration because 
this sweater is warm and comfortable in the cold winter months. The Plan denied your request. The Plan says 
this request does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. The Health 
Plan offers a benefit in excess of Medicare coverage, so the Health Plan rules apply in this case. 
 
We looked at the file and rules. Based on this information, we decided that rules for coverage of the down 
sweater jacket have not been met. Specifically, the down sweater jacket is not a Medicare covered benefit. The 
down sweater jacket is not considered fitness, naturopathic services, acupuncture, nutrition/dietary education, 
weight management programs, eye wear or face masks. This is not a covered benefit under Medicare or the 
Plan. Therefore, we decided that the Plan does not have to pay for a down sweater jacket purchased on 
December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance and localization of a needle or 
catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003) provided on 
October 5, 2021. 
 
You asked the Plan to pay for the fluoroscopic guidance and localization of a needle or catheter tip. You say 
that you would like reconsideration because this service was provided as a separate service. The Plan denied your request. The Plan says CPT code 77003 is an add-on code and was not billed with an appropriate primary 
procedure code. 
 
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 77003 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluoroscopic guidance and localization of a needle or catheter tip for spine or paraspinous diagnostic 
or therapeutic injection procedures (77003) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subarachnoid injection (63230), provided on November 29, 
2021. 
 
You asked the Plan to pay for a subarachnoid injection. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 a subarachnoid injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not contain sufficient information in the medical records 
submitted. In addition, the records submitted were not dated and not signed. 
 
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 subarachnoid injection have not been met. Therefore, we decided that the Plan 
does not have to pay for a subarachnoid injection (63230), provided on November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral Supartz injection (J7321). 
 You asked the Plan to pre-approve Supartz injection. You say that the requested injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Euflexxa. 
 
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 Supartz injection. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has tried and failed the required drug. The reviewer found that there is no 
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. The reviewer also found that the provided records do not include radiographic evidence of 
osteoarthritis in the left knee or failure of conservative treatment for the left knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral Supartz injection (J7321).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine. 
 
You asked the Plan to pre-approve the lumbar CT scan. You say that the fusion mass should be evaluated via 
CT imaging. The Plan denied your request. The Plan says there is no medical reason for this imaging at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the lumbar CT scan. Our reviewer says 
that the requested imaging is not considered reasonable and necessary in this case. Our physician reviewer 
found this 67-year-old male was being treated for lumbar radiculopathy. He is approximately 1-year status post 
L4-5 decompression and fusion. He is doing remarkably well. He denies any back pain and radicular pain. The 
exam reveals intact sensation and strength.  
 
Documentation is not evident regarding any indication of a failed fusion surgery. Radiographs are noted to 
show hardware in appropriate position, with no acute complication. There is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment in this 
clinical scenario. 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 CT of the lumbar 
spine, 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 lumbar CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of heart structure 
(75572). 
 You asked the Plan to pre-approve a CT scan of heart structure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
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 CT scan of heart structure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that catheter ablation is not being carried out nor left atrial occlusion device. Clinical 
guidelines for the use of CCTA have not been met based on review of the submitted clinical documentation. 
 
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 CT scan of heart structure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of heart structure (75572).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
January 3, 2022. 
 
You asked the Plan to pay for a crown. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental work is not a covered benefit. 
 
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 a crown 
(D2740) provided by an out-of-network provider on January 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing care, in the home (S9124) provided on November 
4, 2020. 
 
You asked the Plan to pay for the nursing care, in the home. The Plan denied your request. The Plan says this 
appears to be custodial care services which are excluded. The Plan also says that the enrollee did not contact 
the Plan prior to the services being rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9124 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nursing care, in the home have not been met. 
 
 
 
  Therefore, we decided that the Plan does not have to pay for the nursing care, in the home (S9124) provided on 
November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an auricular nerve stimulator. 
 
You asked the Plan to pre-approve the auricular stimulator. You say that this is necessary as all other options 
for the enrollee's pain have been insufficient. The Plan denied your request. The Plan says this is not a 
Medicare-covered device. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of 
an auricular nerve stimulator.