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

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis provided on April 30, 
2022, by an OON provider. 
 
You asked the Plan to pay for a targeted genomic sequence analysis. You say that it is well established that 
medical providers must render medical treatment in emergency situations. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
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 a targeted genomic sequence analysis provided on 
April 30, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee should not have to wait 3 months for 
another injection. The Plan denied your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. 
 
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 injection. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found there is no documentation 
provided indicating that the previous epidural steroid injection provided at least 50% of sustained improvement 
in pain relief and/or improvement in function measured from baseline using the same scale for at least 3 
months. Therefore, the reviewer found that a repeat ESI 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI) (64483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022. 
 You asked the Plan to pay for the lab services. You say that the test identified possible treatment options for the 
enrollee. The Plan denied your request. The Plan says the documentation does not support the billed date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that there are insufficient medical records to show the billing 
guidelines for the billed date of service have been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hearing aids. You say that you were able to trade in your current hearing aids and 
for an additional $1, 400, you were fitted with the newest aids, which enhanced your word recognition. The 
Plan denied your request. The Plan says services from non-participating providers are not covered under your 
plan unless they are authorized by the Plan before the services are provided. 
 
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 hearing aids provided on March 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was a transplant recipient, and the 
service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 12, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you received a letter 
stating you owed $0. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 the ambulance services provided 
on November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you just had surgery and cannot go up the stairs in 
your home and you need a rehabilitation center. The Plan denied your request. The Plan says the records did 
not show that the enrollee needs skilled therapy or skilled nursing care at least daily that can only be provided 
in a SNF. The enrollee's condition can be managed at home or in an assisted living facility with home health 
services. 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to 
activities of daily living with minimal supervision. The enrollees care needs, custodial and intermittent, can, as 
a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional for frames (V2020), lenses (V2203, V2304), and 
tint (V2744) received on June 1, 2022. 
 You asked the Plan to pay an additional for frames, lenses, and tint. You say that you want the Plan to pay an 
additional amount. The Plan denied your request. The Plan says the benefit maximum allowance had already 
been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $150 benefit maximum. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of frames, lenses, and tint have not been met. Specifically, the record shows that you had exhausted 
your eyewear benefit maximum of $150 and are therefore, responsible for paying the remainder. Therefore, we 
decided that the Plan does not have to pay an additional for frames (V2020), lenses (V2203, V2304), and tint 
(V2744) received on June 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot walk and needs therapy in a 
SNF. The Plan denied your request. The Plan says the records do not show that the enrollee requires daily 
skilled nursing or skilled therapy in a SNF setting. The services the enrollee requires is custodial care. The 
enrollee's needs can be met with long-term care facility with part-time skilled services. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidural steroid injection (ESI) (62323) provided on 
March 24, 2021. 
 
You asked the Plan to pay for the injection. You say that the claim was initially submitted on April 5, 2021, 
and resubmitted on January 5, 2022. You also say that these did not reach the plan. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the injection was not filed until April 27, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the epidural steroid injection (ESI) (62323) provided on March 24, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for the billed service. You say that the reports support the level of service. The Plan 
denied your request. The Plan says that payment for code 70450 is bundled into payment for code 70496. 
 
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. 
 
We looked at the file and the rules. The case file does not include documentation that code 70496 was billed on 
the date of service at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
procedure code 70450 billed for date of service May 3, 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 a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve the repeat injection. You say that you are unable to do another approach. 
You also say that the enrollee will need surgery if pain relief cannot be achieved with epidurals. The Plan 
denied your request. The Plan says the repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents 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. 
 
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 repeat injection. Our reviewer says 
that the requested repeat ESI is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee experienced at least 3 months of 50% pain relief. Therefore, 
the reviewer found that a repeat ESI 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 repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) (62321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on September 30, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the medical 
records submitted do not support a hospital discharge day management of more than 30 minutes was 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no indication based 
on the medical records that more than 30 minutes were spent providing the services in question. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services 
have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day 
management services (99239) provided on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service April 24, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76770 is bundled into 
payment for code 70450. 
 
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 76770 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service April 24, 2022.
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 is not medically 
necessary. 
 
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 documentation shows that the enrollee would be expected to continue to require close medical 
monitoring after having multiple complications thus requires inpatient hospital level of care. Evaluating 
therapists recommend intense therapy and the enrollee requires 3 disciplines thus IRF criteria has been met and 
is medically 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #4 (D6010), an abutment 
supported crown on tooth #4 (D6061), a prefabricated post on tooth #4 (D6056), and a pontic on tooth #5 
(D6242). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there needs to be at least eight permanent back teeth that bite 
together. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that a review of the documentation 
indicates that multiple posterior teeth are missing bilaterally in the maxilla. The documentation provided does not meet the criteria for coverage for the implant fixed bridge in the maxillary right quadrant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an endosteal implant on tooth #4 (D6010), an abutment supported crown on tooth #4 
(D6061), a prefabricated post on tooth #4 (D6056), and a pontic on tooth #5 (D6242).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services is the most appropriate 
level of care for the enrollee and the enrollee fully meets the LTACH admission criteria. The Plan denied your 
request. The Plan says the records do not show that the enrollee is expected to get better with LTACH care. 
The enrollee can safely receive this care in another setting like a skilled nursing facility or at home with home 
health services or outpatient setting. 
 
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 that the enrollee appears to still be somewhat unstable and requires only short-term 
additional acute care hospital services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically at this time as 
it would not be clinically advantageous. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.