Persius/hicric huggingface dataset:
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 needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 pre-approve retainer crowns (D6740) for teeth # 13 and 15, and a 
pontic (D6245) for tooth # 14. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says your benefit for the requested services have 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. The record 
shows the Plan paid for crown services that you received on teeth # 13 and 14 on September 17, 2021, and for 
tooth # 15 that you received on August 25, 2021. Therefore, we decided that the Plan does not have to pre-
approve retainer crowns (D6740) for teeth # 13 and 15, and a pontic (D6245) for tooth # 14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations. 
 
You asked the Plan to pre-approve radiofrequency ablations. You say that your pain is detrimental to your 
quality of life. The Plan denied your request. The Plan says you have only had one set of diagnostic medial 
branch blocks. 
 
The Plan follows Medicare rules. Medicare rules state that therapeutic facet joint injections may be covered if 
certain criteria are met, including that 2 diagnostic facet joint procedures have been completed. 
 
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 radiofrequency ablations. Our reviewer 
says that you do not meet criteria for the requested radiofrequency ablations. Our physician reviewer found you 
have not had a second diagnostic facet procedure to confirm the validity of the first diagnostic facet procedure 
at the same level. Therefore, this request is not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 home tests purchased on 
January 12, 2022. 
 
You asked the Plan to pay for OTC COVID-19 home tests. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if you are in a Medicare Advantage (MA) plan, 
the tests covered under this initiative will be covered outside of your existing plans coverage, and in addition 
to any over-the-counter tests that may be covered under the plan as a supplemental benefit. The Medicare rules 
also say that this initiative started on April 4, 2022. 
 We looked at the file and Medicare rules. This test is not covered by Medicare because it was purchased prior 
to April 4, 2022. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) COVID-
19 home tests purchased on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 12, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says services from 
non-par providers are not covered under an HMO plan unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 4, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the prosthetic leg with an advanced knee/foot feature (CPT code(s): L5828, L5845, L5848, L5856 and L5981).

You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is necessary. The Plan denied your request. The Plan says that the request for K3 knee and foot does not meet Medicare criteria as 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 the prosthesis. Our physician reviewer found the documentation provided does support the enrollee being a K3 level ambulator. Per the prosthetic note dated September 21, 2022, the enrollee has been improving in terms of their strength with physical therapy and the enrollee is currently using a cane for assistance with mobility. The enrollee cannot progress to higher level of mobility given that his existing K2 level knee and foot limit the enrollee's mobility. The enrollee can ambulate with variable cadence and on uneven terrain and the clinical progress note indicates that the enrollee has sufficient cardiorespiratory function to accomplish this. The enrollee's current prosthetic socket is no longer fitting due to volume change in the enrollee's residual limb and their components do not meet the enrollee's mobility needs. Therefore, the microprocessor controlled prosthetic knee and Ottobock Triton K3 prosthetic foot are 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 the prosthesis have been met. Therefore, we decided that the Plan has to pre-approve the prosthetic leg with an advanced knee/foot feature (CPT code(s): L5828, L5845, L5848, L5856 and L5981).

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 pay for anesthesia for procedures on the forearm, wrist, and hand 
(code 01810) provided on May 18, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the forearm, wrist, and hand. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on August 16, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for anesthesia for procedures on the forearm, wrist, and hand have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on 
the forearm, wrist, and hand (code 01810) provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during a hospital stay from 
June 14, 2022, to June 18, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that no one can bring their own medication into 
a hospital. You say medications are brought to the patient not even knowing what the doctor has prescribed. 
The Plan denied your request. The Plan says self-administered medication is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
during a hospital stay from June 14, 2022, to June 18, 2022.   
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sclerotherapy provided on August 24, 2022, and  
August 31, 2022. 
 
You asked the Plan to pay for sclerotherapy. You say that you are having a lot of pain around your ankles, 
especially on the right side, but on the left as well. You say that this is not cosmetic but is to relieve the pain 
and swelling in your legs. The Plan denied your request. The Plan says sclerotherapy for telangiectasias is 
widely considered cosmetic and specifically is not covered by the health Plan. There has to be significant 
extenuating circumstances to consider coverage of this treatment. 
 
The Plan follows Medicare rules. 
 
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 sclerotherapy. Our reviewer says that the 
requested sclerotherapy is not medically necessary. Our physician reviewer found that based on the medical 
records provided there is no documentation that the sclerotherapy provided on August 24, 2022 and  
August 31, 2022 at issue in this case meets all Medicare criteria for medically reasonable and necessary. The 
provided records do not document that you had pain or burning in the extremity severe enough to impair 
mobility or recurrent episodes of superficial phlebitis or non-healing skin ulceration or bleeding from a 
varicosity or stasis dermatitis or refractory dependent edema as required by the Local Coverage Determination 
Treatment of Varicose Veins of the Lower Extremities - (L34010).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pay for sclerotherapy provided on August 24, 2022, and August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve block. 
 
You asked the Plan to pre-approve a nerve block. You say that a nerve block is medically necessary. The Plan 
denied your request. The Plan says a nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a nerve block have been met. 
Specifically the medical records have not been provided. Therefore, we decided that the Plan does not have to 
pre-approve a nerve block.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from February 5, 2021, through 
February 15, 2021, at the initially billed Diagnosis Related Group (DRG). 
 
You asked the Plan to pay for the inpatient services as billed. You say that this should be paid at the original 
DRG. The Plan denied your request. The Plan says that this case was forwarded as the Plan missed the time 
frame. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the file does not include sufficient information to support the denial 
of the billed DRG. Although the Plan indicated that it would have overturned the denial, it was not confirmed 
that payment was made for these services. It is not clear from the file which diagnosis code was at issue, and as 
such, we cannot review this issue. We find that the denial of payment is not supported. Therefore, we decided 
that the Plan has to pay for the inpatient hospital care provided from February 5, 2021, through February 15, 
2021, at the initially billed Diagnosis Related Group (DRG).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99291 is bundled into payment for code 36556. 
 
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 99291 
is a column II code to column I code 36556. 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 99291 billed for date of service April 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 24, 2022, to 
July 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services provided were 
correctly billed and were medically necessary. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 24, 2022, to July 
23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for orthotics (L0650, L1833) provided on September 23, 2020. 
 
You asked the Plan to pay for the orthotics. You say that these items were medically necessary. The Plan 
denied your request. The Plan says that they were unable to make a determination on the appeal in a timely 
matter. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not sufficiently articulated their reason for the denial. The records 
include a physician's order for the requested items, medical records detailing the need for these items, and 
shipping documentation. Therefore, we decided that the Plan has to pay for orthotics (L0650, L1833) provided 
on September 23, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept provided on July 11, 2022. 
 
You asked the Plan to pay for paramedic intercept. You say that you would like reconsideration because the 
requested paramedic intercept is medically necessary. The Plan denied your request. The Plan says the 
requested paramedic intercept is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 23, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 2, 2022.