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

 
We decided that the Plan does not have to pre-approve replacement of a permanent pacemaker. 
 
You asked the Plan to pre-approve replacement of a permanent pacemaker. 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 must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement of a permanent pacemaker have not been met. Specifically, medical records for the 
correct enrollee were not provided. Without this documentation, medical necessity is not able to be established. 
Therefore, we decided that the Plan does not have to pre-approve replacement of a permanent pacemaker.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says the additional 
visits are not medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that 11 home health skilled nursing visits were requested. The Plan has agreed to pre-approve 4 
visits. 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 additional visits. Our physician 
reviewer found that the enrollee has been receiving home health care for management of the Foley catheter. 
The documentation indicates he has had a healing skin tear and no complications from the Foley. There is no 
indication that the enrollee has a feeding tube, parental medications, or complex wound care issues. There is no 
indication that he had any recent medication changes or hospitalizations. There has not been a recent decline in 
function. He has been medically stable. He does not require additional skilled nursing services to effectively 
provide treatment in order to improve his condition or perform a maintenance program to maintain his 
condition or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic cancer risk assessment provided on September 
27, 2021, billed with codes 81408, 81292, 81321, and 81407. 
 
You asked the Plan to pay for the genetic testing. You say that the records support that this should be covered. 
The Plan denied your request. The Plan says certain codes were approved on appeal. However, the remainder 
represent individual gene codes for a panel of genes tested in parallel. As such, this should be reported with a 
single panel code. 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. Multiple genes were evaluated with a next generation sequencing 
procedure. This should be reported as a single panel code. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic cancer risk assessment provided on September 27, 2021, billed with codes 81408, 81292, 
81321, and 81407.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crown (code D2740) you received on November 
23, 2021. 
 
You asked the Plan to pay for the dental crown. You say that you believe you are covered for crowns under 
your comprehensive dental benefits, even if out-of-network. The Plan denied your request. The Plan says this 
service is not covered under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  Your contract says that only those dental services explicitly listed in 
your benefits chart are covered.  Dental crowns (code D2740) are not listed as covered dental services. 
Therefore, we decided that the Plan does not have to pay for the dental crown (code D2740) you received on 
November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the documentation provided supports the need for the 
requested drug. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Ilumya. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the records provided report the enrollee 
stated she had spots all over her body including genital area and buttocks with itching present. Physical 
examination reports the enrollee appeared well nourished and in no acute distress. Detailed skin examination 
reports the enrollee's psoriasis has affected the skin on her face at right eyebrow level, as well as her arms and 
legs, back, buttock and buttock crease, perineum and vulva. The provider assessment reports psoriasis is at 
more than 10% of the enrollee's total body surface area. Documentation provided reports the enrollee was seen 
by the provider on April 21, 2021, for a psoriasis flare up lasting 2 months. The documentation provided 
reports the enrollee was treated for her last visit, but insurance did not cover "a lot of the medication." The 
medical records indicate the enrollee is not taking any medication for treatment of her psoriasis as of March 11, 
2022. The clinical documentation provided does not indicate that the enrollee has tried and failed other 
treatment methodologies covered by the health plan such as Enbrel, infliximab, methotrexate, or cyclosporine 
for at least 3 months of duration. The medical records provided do not include any reasons and/or 
contraindication that substantiate why the enrollee could not have used any other medication for treatment. The review has determined that the documentation does not support that the Ilumya is medically reasonable and 
necessary for the enrollee. The documentation does not support that the Ilumya is safe and effective for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0430), and air mileage (A0435) provided on October 8, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the enrollee was transported at the 
request of their provider. The Plan denied your request. The Plan says the air ambulance transport was not 
medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance transport is not medically necessary. Our physician reviewer found the 
documentation supports that the enrollee suffered from an illness or injury that contraindicates transportation 
by any means other than ambulance. The documentation did not support that the enrollee's condition was such 
that the time needed to transport them by ground, or the instability of transportation by ground, posed a threat 
to the enrollee's survival or seriously endangered the enrollee's health. The reviewer also found that the 
documentation did support that the transferring hospital did not have adequate facilities to provide the medical 
services needed by the enrollee. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0430), and 
air mileage (A0435) provided on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from September 17, 2021, to October 8, 2021. 
 
You asked the Plan to pay for the IRF care. You say that it is felt that the enrollee received medically necessary 
treatment during this stay and that the stay should be covered. The Plan denied your request. The Plan says the 
original denial was correct. The enrollee's needs could have been met in a subacute rehabilitation facility.  
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 pay for the IRF care. Our reviewer says that the IRF 
care provided is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs did not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical management of an ulnar fracture and non surgical management of a right tibial plateau 
fracture. Medical problems were stable. There were no complex nursing or rehabilitation needs. The patient did 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient had a need for physical and/or occupational therapy, 
there was no documentation of a need for an intensive rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from September 
17, 2021, to October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tenodesis of long tendon of biceps (23430) provided on 
August 12, 2021. 
 
You asked the Plan to pay for the tenodesis of long tendon of biceps (23430). You say that access to the joints 
and spaces of the shoulder are singular to the given structure and that access to different areas requires separate 
and distinct portals or incisions. You say that CPT code 23430 is eligible for separate reimbursement. The Plan 
denied your request. The Plan says CPT code 23430 is considered inclusive to CPT code 23472. 
 
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 23430 is a column II code to column I code 23472; however, 23430 
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 tenodesis of long tendon of biceps (23430). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report documents a reverse total shoulder arthroplasty and biceps tenodesis performed 
on the right shoulder. Per CMS, a bicep tenodesis is not separately reported, when performed on the same 
shoulder. 
 
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 tenodesis of long tendon of biceps (23430) have not been met. Therefore, 
we decided that the Plan does not have to pay for the tenodesis of long tendon of biceps (23430) provided on 
August 12, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and used oxygen via nasal cannula. The enrollee was at a standby assist to contact guard assist 
level for functional mobility including gait to 270 feet. The enrollee does not require skilled nursing or therapy 
services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided January 7, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you were told by a plan representative that your 
dentist is in-network. The Plan denied your request. The Plan says the claim for this date of service has been 
reprocessed as in-network, however the core buildup is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950) provided January 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for ambulance transport provided on
May 8, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to waive the cost share charged for ambulance transport
provided on May 8, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the enrollee has chronic hidradenitis 
suppurativa that has been resistant to most other treatments. You say that the clinical information provided 
supports the need for the requested treatment. The Plan denied your request. The Plan says that research studies 
have found a lack of proof that routine use of the requested type of treatment would improve the outcome for 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 radiation therapy. Our reviewer says 
that radiation therapy is considered medically reasonable and necessary in this case. Our physician reviewer 
found hidradenitis suppurativa (HS) is a rare condition commonly managed surgically or with antibiotics. For 
treatment resistant disease, radiotherapy can be considered. A systematic review identified 9 articles with 122 
patients that met the studys inclusion criteria. The authors concluded Radiotherapy appears to be an option 
for patients with treatment-resistant HS or who are poor surgical candidates. However, there remains a paucity 
of consensus on proper candidate selection, dosing, efficacy, and safety of the short- and long-term effects of 
radiotherapy. For this patient, the consult note describes multiple courses of antibiotics and surgeries for what 
is a chronic condition in this patient. Radiotherapy appears to be reasonable option given the resistance to other 
treatments. The prescribed dose and fractionation are in line with published data. The records show what 
appears to be large complex field for which 3D radiation (vs 2D radiation) would be an accepted standard even 
with such a low dose. The treatment prescribed would be 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 radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy.  
 
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 for dental services provided by a participating provider on 
November 2, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the maximum dental allowance amount of $1,250 has already been met and 
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. The Plan covers dental 
services up to a total allowance amount of $1,250.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have already been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a participating provider on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids purchased on November 8, 2021.
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because hearing aids from the Plan's network providers would cost substantially more. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor's network
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from a provider that is in the Plan's network. We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, hearing aids purchased from a provider who is not in the Plan's network are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on November 8, 2021.