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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
the admission is not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 18, 2022 and received physical therapy. The physical therapy note dated August 22, 2022 
states she needs assistance with walking 110 feet with a walker. She has no skilled nursing or skilled therapy 
needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the 
enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85027) provided on February 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-approved or emergent. There were 
network providers available. 
 
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 lab services (85027) provided on February 3, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the records provided support the need 
for a CardioMEMS system. The Plan denied your request. The Plan says the request is not medically necessary 
because the records do not show that the enrollee has been hospitalized within the last year for heart failure. 
 
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 CardioMEMS system. Our reviewer 
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 2, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-approved or emergent. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 (99214) provided on March 2, 2022 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve lumbar ESI services. You say that the injection services are medically 
necessary to provide the enrollee relief while he awaits surgery to improve his function. You say that the 
clinicals provided support the need for the requested injection services. The Plan denied your request. The Plan 
says the notes show the enrollee has already had 4 sessions in the last twelve months. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of 4 sessions per 
spinal region in a rolling 12-month period. 
 
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 lumbar ESI services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has low back pain 
and bilateral lower extremity pain consistent with lumbar radiculopathy.  The records indicate that the enrollee 
has had the following lumbar epidural steroid injections over the past 12 months: bilateral L4-L5 
transforaminal ESI (TFESI) on September 14, 2021; bilateral L2-L3 TFESI on October 29, 2021; bilateral L5-
S1 TFESI on April 21, 2022; bilateral L2-L3 TFESI on May 31, 2022; and bilateral L2-L3 TFESI on July 26, 
2022. The provider has requested a repeat ESI in the at L2-3 level via interlaminar approach. The enrollee has 
already reached the maximum of 4 sessions per spinal region in a rolling 12-month period for the lumbar spinal 
region. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar ESI services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar epidural steroid injection (ESI) services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #8 (D2740). We also decided that the Plan does 
not have to pre-approve an occlusal guard (D9944) and core build up on tooth #5, 9, 11, 14, 15, and 31 
(D2950).  
 
 You asked the Plan to pre-approve a crown, a guard and core build up. You say that these services are 
medically necessary.  The Plan says that a crown is not medically necessary because the tooth does not have 
decay. The Plan also says that an occlusal guard (D9944) and core build up (D2950) are not covered by the 
enrollees dental benefits. 
 
We decided that the Plan has to pre-approve a crown on tooth #8 (D2740). 
 
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 a crown 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 a crown. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that a review of the documentation indicates a 
significant fracture on tooth #8 involving the mesio-incisal angle. The physician reviewer also says that a 
crown restoration is reasonable and necessary to provide adequate function and to prevent further fracture. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #8 (D2740).  
 
We also decided that the Plan does not have to pre-approve an occlusal guard (D9944) and core build up 
on tooth #5, 9, 11, 14, 15, and 31 (D2950). 
 
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, an occlusal guard and core build up  
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve an occlusal guard (D9944) and core build up on tooth #5, 9, 11, 14, 15, and 31 (D2950). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87426) provided March 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and required 
by the state of Hawaii. The Plan denied your request. The Plan says this service was for screening purposes as a 
prerequisite to travel and is non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
services (87426) provided March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Qutenza (J7336). 
 
You asked the Plan to pre-approve Qutenza. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has been prescribed for an off-label and medically unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Qutenza. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
Qutenza is not FDA-approved for chronic pain syndrome with neuralgia and neuritis, unspecified. The 
requested use of Qutenza is not supported by one of the major drug compendia or by clinical research that 
appears in a Medicare-approved medical journal. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Qutenza (J7336).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (82075, 80305, 99212) provided on January 6, 
2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 (82075, 80305, 99212) provided on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polypectomy surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the polypectomy surgery. You say that you were referred to this out-of-
network provider by your physician. The Plan denied your request. The Plan says the services have been 
requested out-of-network and there are in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the polypectomy surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the services were medically necessary. 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 February 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
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 the lab 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 lab services provided on December 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 31, 
2022 to April 26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. 
 
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 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 services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on January 31, 
2022 to April 26, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bed (A9901, E1399, S9999) provided July 17, 2021. 
 
You asked the Plan to pay for the bed. You say that the bed was medically necessary and should be covered. 
The Plan denied your request. The Plan says the bed is not a medical item and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a bed (A9901, E1399, S9999) provided July 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided February 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was missing required information. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers must submit the following claim information: the appropriate CPT code, 1 unit of service, and the 
appropriate DEX Z-Code. 
 
We looked at the file and Medicare rules. The claim was not billed with an appropriate DEX Z-code. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (0037U) provided February 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound of the heart for congenital defect. 
 
You asked the Plan to pre-approve an ultrasound of the heart for congenital defect. 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 follows Medicare rules. Medicare rules say that stress echocardiography may be indicated in the care 
of patients with real or suspected ischemic heart disease in certain clinical settings. 
 
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 an ultrasound of the heart for congenital 
defect. Our reviewer says that the services are not medically necessary. Our physician reviewer found at issue 
is the medical necessity of a transthoracic echocardiography (TTE) to rule out a congenital heart defect, in the 
absence of any cardiovascular abnormalities on physical examination. Clinical guidelines do not support 
carrying out a TTE in this setting. In summary, there is no supportive evidence for the medical necessity of a 
TTE in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasound of the heart for congenital defect have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an ultrasound of the heart for congenital defect.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appear to be more stable and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for discharge 
home for continued palliative treatment. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to LTACH is not medically necessary 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 long term acute care hospital (LTACH) services.