Persius/hicric huggingface dataset:
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 you receive oral medications. You have stable
vital signs and use oxygen via nasal cannula. You do not require skilled nursing or therapy services on a daily
basis. You do not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine laboratory services (36415 and 85025) provided
on October 1, 2021. You asked the Plan to pay for the routine laboratory services.. You say that you would like reconsideration
because these labs were ordered as a part of your wellness exam. The Plan denied your request. The Plan says
labs for screening purposes are not 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 routine laboratory 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 the routine laboratory services (36415 and 85025) provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of intravenous ultrasound (IVUS) during the
diagnostic angiography and potential stenting.
You asked the Plan to pre-approve the requested IVUS. You say that it is felt that this treatment is needed
urgently to improve blood flow due to critical limb ischemia. The Plan denied your request. The Plan says the
services have been approved, other than the IVUS which is not considered to be medically necessary for this
procedure.
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 the requested IVUS. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has documented lower extremity arterial disease with ulceration for which
diagnostic angiography and intervention, if required, is reasonable. This has been approved by the Plan.
At issue is the medical necessity of the use of IVUS in this setting. In the documentation provided, there is no
clear notation of how IVUS would be used or why it is required. While lower extremity arterial IVUS is a
known entity, there currently is insufficient evidence of superiority with the use of arterial IVUS this that it
would warrant overturning the health plan determination. Additionally, in the physician's appeal letter, there is
no mention of the need for IVUS.
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 requested IVUS have not been met. Therefore, we decided that the Plan
does not have to pre-approve the use of intravenous ultrasound (IVUS) during the diagnostic angiography and
potential stenting.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for home health services provided on May 31, 2021, through July 4, 2021.
You asked the Plan to pay for the home health services. You say that you would like reconsideration because
this claim was submitted by the member for reimbursement and all past claims have been overturned in the
member's favor. The Plan denied your request. The Plan says that home health providers must submit claims on
the UB-04 form.
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. Specifically, the Plan's denial rationale based on the provider not submitting this
claim on a UB-04 is not valid. This is a member claim for reimbursement. The Plan has not forwarded any
additional information to validate why this service has been denied. It is the burden of the Health Plan to
substantiate their denial with evidence. In this case the Plan's denial has not been substantiated so we must find
in your favor. Therefore, we decided that the Plan has to pay for home health services provided on May 31,
2021, through July 4, 2021.
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: 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 you do not require skilled nursing services,
and the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and
effectively provide medically necessary and reasonable treatment. Daily skilled services are not required.
Services in a long-term care facility on a part time basis, if you are able to participate in the future, appear
appropriate in this case.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that this procedure would be beneficial.
The Plan denied your request. The Plan says this is not a proven treatment.
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 the Superion procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Superion spacer is considered experimental for back pain. 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 Superion procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tramadol 50mg tablets.
You asked the Plan to pre-approve the tramadol tablets. You say that this is a necessary drug. The Plan denied
your request. The Plan says this oral drug is not covered by Medicare Part B.
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 pre-approve tramadol 50mg tablets. Benefits for the tramadol tablets 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 radiofrequency ablation of the peripheral nerves of the knee (procedure code 64640) for the treatment of knee pain.  You asked the Plan to pay for the radiofrequency ablation procedure. You say that your doctor told you that this procedure would take care of your pain for a year. The Plan denied your request. The Plan says this service is not a covered benefit for your condition.  The Plan must follow Medicare rules. Medicare rules say that the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Although this service may be helpful for you, Medicare does not cover the requested service for your condition. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation of the peripheral nerves of the knee (procedure code 64640) for the treatment of knee pain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow knee injections.
You asked the Plan to pre-approve the requested Fluid Flow injections. You say that the requested treatment
would be beneficial for the enrollee's condition. The Plan denied your request. The Plan says this is not Food
and Drug Administration (FDA) approved and not supported by current literature.
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 the requested Fluid Flow injections.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this treatment is purely experimental for the treatment of knee pain 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 the requested Fluid Flow injections have not been met. Therefore, we decided
that the Plan does not have to pre-approve Fluid Flow knee injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided on
July 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you found the provider on
the website and they confirmed they were accepting your Plan. You also say that this exam should not be
denied. The Plan denied your request. The Plan says the maximum allowed benefit for an oral exam has been
met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a
comprehensive oral evaluation once every 6 months. We looked at the file and Medicare rules. The records show that you had a limited oral evaluation on January
18, 2021, therefore, you have exhausted your benefit for this service. Based on this information, we decided
that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided
that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided on July 6, 2021,
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 critical care services rendered on October 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
a critical care visit of 30-74 minutes. 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 pay for the critical care
services rendered on October 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron 8mg tablets.
You asked the Plan to pre-approve the ondansetron tablets. You say that this is needed to prevent nausea and
vomiting. The Plan denied your request. The Plan says Part B does not cover this drug for oral use except when
given within hours of chemotherapy sessions.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although anti-emetics can be covered when administered on the same day as oral anti-cancer drugs, this
request is for prevention of nausea beyond the same date as anti-cancer therapy. As such, Part B coverage does
not apply to this request. Therefore, we decided that the Plan does not have to pre-approve ondansetron 8mg
tablets.
Benefits for the ondansetron tablets 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 pre-approve infectious disease specialist services to be provided by
an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON infectious disease services. You say that you were treated in the
hospital by the OON provider and put on intravenous antibiotics. You wish to be able to follow up with this
provider. The Plan denied your request. The Plan says you have established care with in-network infectious
disease specialists who can assume your hospital follow-up care. There is no medical need for outpatient
referral to the OON provider.
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
infectious disease specialist services to be provided by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953), conscious sedation,
initial 15 minutes (D9239), and conscious sedation, additional 15 minutes (D9243 x 3) provided on
October 7, 2021.
You asked the Plan to pay for the dental services. You say that your dental problem is not from neglect. You
also say that you would like it if your insurance would cover half of the cost. The Plan denied your request. The
Plan says bone replacement graft is not listed as a covered service. The Plan says that conscious sedation
services are not listed as covered either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft and
conscious sedation services are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to pay for the bone replacement graft (D7953), conscious sedation, initial 15 minutes (D9239),
and conscious sedation, additional 15 minutes (D9243 x 3) provided on October 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 21, 2021.
You asked the Plan to pay for the ambulance services. You say that the ambulance transport provided on
September 21, 2021, was medically necessary. The Plan denied your request. The Plan says the ambulance
transport provided on September 21, 2021, was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same 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 the ambulance services. Our reviewer says
that the ambulance transport provided on September 21, 2021, was not medically necessary. Our physician
reviewer found the record indicates that the enrollee has chronic back pain that was worsening over the past
few days and had an exacerbation while working the day previous. The record indicates that the enrollee was
able to ambulate and had no deficit. A prudent layperson would not believe this condition to be life threatening
without immediate medical attention. The record does not indicate that the enrollee required the skill and
expertise of an ambulance unit. The record indicates that the enrollee could have been transported using
alternate modes of transportation. The elements of the coverage criteria are not satisfied. The requested service
cannot be 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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance services provided on September 21, 2021
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the aortography (75625) provided on April 8, 2021.
You asked the Plan to pay for the aortography (75625). You say that the first page of the operative note states
the catheter was introduced into the intrarenal abdominal aorta and an angiogram was performed. You say that
you disagree with the denial and the claim should be paid. The Plan denied your request. The Plan says that
procedure code 75625 is not supported by the medical records.
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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation.
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 aortography (75625). Our reviewer says that the
documentation submitted was reviewed and does meet the criteria for coverage. Our reviewer found that the
procedure report supports an aortography, abdominal by serialography.
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 aortography (75625) have been met. Therefore, we decided that the Plan has
to pay for the aortography (75625) provided on April 8, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain
rendered on September 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the
head/brain rendered on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cinacalcet 90mg tablets.
You asked the Plan to pre-approve the cinacalcet tablets. You say that this is needed. The Plan denied your
request. The Plan says this oral drug cannot be covered by Part B. However, Part D coverage has been
approved.
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 pre-approve cinacalcet 90mg tablets. Benefits for the cinacalcet tablets may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.