Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine provided to you on June 30, 2021. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not 
covered under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine provided to you on June 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the enrollee has chronic neck pain. She is status post cervical spine surgery, but the details 
of levels are not delineated. She takes Gabapentin for pain. She had a first set of diagnostic MBBs, which 
produced 50% pain relief, and a second set which gave her 90% pain relief. The coverage criteria requires that 
both diagnostic sets produce greater than 80% pain relief. Only the second set did and therefore, the request is 
deemed not medically reasonable or necessary. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not able to stand or walk on your own. 
The Plan denied your request. The Plan says you are at or close to your baseline. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and was treated for 
respiratory failure. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, 
you were at a standby to contact guard assist level with functional mobility. You required varying assist with 
activities of daily living. Although there are identifiable skilled therapy service needs, you do not require 
skilled nursing or therapy services on a daily basis. You do not meet 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042, 11045) and the 
home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network 
(OON) provider on May 3, 2021 and May 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 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 the subcutaneous tissue debridement (11042, 11045) and the home visit for the 
evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider 
on May 3, 2021 and May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (22899 and C9752).
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.
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 Intracept procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found he clinical value and effectiveness of the Intracept procedure in the setting of this enrollee's diagnosis has not been demonstrated in the peer-reviewed literature. 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 Intracept procedure have not been met. Specifically, more research is needed for this procedure, and at this time is considered experimental, which means the procedure is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure (22899 and C9752).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the glycated hemoglobin testing provided on March 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON lab testing. You say that this testing is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this non-emergency testing was provided OON and was ordered by an OON physician. No authorization was requested for these services.
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 the glycated hemoglobin testing provided on March 4, 2021 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 excision of facial bone (21026 x 2), excision of benign tumor or cyst of mandible (21040 x 2), impression and custom preparation for an oral surgical splint (21085), alveoloplasty, each quadrant (41874 x 2), excision of benign tumor or cyst of maxilla or zygoma (21030), and panoramic x-ray (70355) provided on April 30, 2021.
You asked the Plan to pay for the dental services. You say that you switched plans before you received these services. You say that you did not inform your dentist of this switch prior to receiving the services. You say that had you informed your dentist of this change, they would have taken the appropriate steps needed to make sure it would be covered. You also say that you feel the services should be covered. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that dental services are not covered by Medicare. The Plan also says that the services were denied correctly.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the excision of facial bone (21026 x 2), excision of benign tumor or cyst of mandible (21040 x 2), impression and custom preparation for an oral surgical splint (21085), alveoloplasty, each quadrant (41874 x 2), excision of benign tumor or cyst of maxilla or zygoma (21030), and panoramic x-ray (70355) provided on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. 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 health plan. The requested LTACH services 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on June 18, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a screening colonoscopy with no copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
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 did not submit medical records or a claim form showing a diagnosis of anemia. This means the Plan did not show that the colonoscopy was diagnostic in nature. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided on June 18, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for facial prosthetics (L8042, L8043) provided on February 16, 
2021. 
 
You asked the Plan to pay for facial prosthetics. You say that these items were authorized. The Plan denied 
your request. The Plan says these items are not supported in the records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. This documentation was not submitted. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for facial prosthetics (L8042, L8043) provided on 
February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 you were admitted with hypoxic respiratory failure due to Coronavirus pneumonia. 
The record indicates that you have had a prolonged hospital course, most recently having a gastrointestinal 
bleed requiring transfusion and is otherwise medically unstable at this time. You continue to receive acute care 
services, and these have not been denied. The medical record does not indicate that you require services that 
you are not currently receiving but that would be available at the LTACH facility. The elements of the 
coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing 
skilled therapy and nursing needs can be met in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. The enrollee 
is taking Norco for pain. The enrollee had physical therapy two years ago. The enrollee had diagnostic 
genicular nerve blocks on August 2, 2021, and August 16, 2021, which produced 80% pain relief. The 
requested procedure is considered experimental/investigational and is the subject of ongoing clinical trials. The 
enrollee is not enrolled in a clinical trial. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hernia repair procedures provided on June 30, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for hernia repair procedures. You say that the requested services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not 
been met. 
 
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 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 hernia repair procedures 
provided on June 30, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 24 additional routine transportation trips. 
 
You asked the Plan to provide additional routine transportation. You say that this transportation is necessary for 
you to get to your medical appointments. The Plan denied your request. The Plan says trips in excess of the 48 
one-way trips provided by your routine transportation benefit are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide 24 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on April 5, 
2021. 
 
You asked the Plan to pay for clinic visit G0463. You say that the enrollee is currently under an active 
treatment plan with this provider. The Plan denied your request. The Plan says the denial of payment for this 
code is correct, because a corrected claim is required to cover code G0463. 
 
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 clinic 
visit G0463 is a column II code to column I code 96409. 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 a hospital outpatient clinic visit (G0463) provided 
on April 5, 2021.