Persius/hicric huggingface dataset:
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 reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 patient was admitted for a stroke and was discharged to inpatient 
rehabilitation on May 15, 2022, then discharged home on May 27, 2022. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable 
expectation that this patient 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided from November 11, 2021, to December 18, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 11, 2021 to December 18, 2021. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment, no transport, (A0998) provided from November 11, 2021, to December 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on January 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a chest X-ray. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment 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 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 an X-ray of the chest (71045) provided on January 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a procedure to increase blood flow to bilateral iliac 
arteries. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria required by the health plan has not been met to determine if the 
procedure is needed. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although it is unclear from the records what the patients symptoms are, and the physical 
examination was not performed as the visit was over the telephone without video, there is duplex 
documentation of infrainguinal peripheral artery disease and coverage for imaging and treatment for these 
territories has already been approved by the health plan. At issue is the additional codes for treatment of the 
iliac arteries. As none of the records suggest aortoiliac disease, preapproval for treatment of these territories has 
not been approved. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a procedure to increase blood flow to bilateral iliac arteries.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft services. 
 
You asked the Plan to pre-approve the requested services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says the clinical value has not been demonstrated in peer-reviewed 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 services. Our physician 
reviewer found that you are being treated for spinal instabilities, occipito-atlantoaxial region. The procedure 
Occiput-C2, C1-2 spine fusion procedure with inpatient admission has been approved. However, there is 
limited published, large-scale, long-term peer-reviewed literature that shows the requested allograft to be an 
effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested ViviGen allograft for use with spinal fusion, in this case, is 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 allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental drugs (D9630) and an unspecified preventative 
procedure (D1999), provided by a participating provider on March 18, 2022. 
 
You asked the Plan to pay for dental drugs and an unspecified preventative procedure. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the rendered services have been 
processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
drugs (D9630) and an unspecified preventative procedure (D1999), provided by a participating provider on 
March 18, 2022.  
 This appeal does not address periodontal maintenance (D4910). D4910 has been processed and paid according 
to the 2022 EOC.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve anesthesia services (00142) provided on January 28, 2022. 
 
You asked the Plan to pre-approve anesthesia services. You say that the anesthesia services at issue should be 
billed separately. The Plan denied your request. The Plan says that rules for payment have not been met 
because the anesthesia services at issue are inclusive to another billed code. 
 
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 states that payment for procedure code 00142 is 
included in the payment for another billed code. The Plan has not provided any evidence of the other billed 
code. The Plan has not provided additional evidence to indicate why code 00142 cannot be paid. It is the 
burden of the Plan to substantiate its denial with evidence. In this case, the Plans denial is not substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pre-approve anesthesia services (00142) 
provided on January 28, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for the services (99233) provided on September 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate 
claim. 
 
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 argues that this is a duplicate claim to one previously paid. However, 
the Plan has not provided documentation showing that code 99233 was paid on a separate claim for date of 
service September 11, 2021. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services (99233) provided on September 11, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy surgery. 
 
You asked the Plan to pre-approve a knee arthroscopy surgery. You say that the records provided support the 
need for the requested procedure. The Plan denied your request. The Plan says an imaging study that shows a 
torn meniscus in the knee that matches with symptoms and a doctor exam was not provided. 
 
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 knee arthroscopy surgery. Our 
reviewer says that a knee arthroscopy surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a recent examination to 
corroborate ongoing subjective complaints and objective deficits. Additionally, the x-rays demonstrated 
significant arthrosis/arthritis in the right knee. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. 
 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 knee arthroscopy surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a knee arthroscopy surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have pay the in network rate for the inpatient hospital care provided from 
January 20, 2022, to January 21, 2022, by the out of network provider. 
 
You asked the Plan pay the in network rate for the inpatient care. You say that you were admitted through the 
emergency room for a serious infection. You say that a specialist was called in to see you. You say that you did 
not have a choice of which doctor they chose to see you. You also say that you do not feel you should be 
responsible for this balance. The Plan denied your request. The Plan says that the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for inpatient hospital care.  
 
 You have been asked to pay 40% coinsurance for the inpatient care performed by an out of network provider. 
The inpatient care received out of network falls within the inpatient hospital care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have pay the in network rate for the inpatient hospital care provided from January 20, 2022, to January 
21, 2022, by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 the services (70450) provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on March 16, 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 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 83789 is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the mass spectrometry rendered on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service cannot be approved until its efficacy has been established. 
 
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 services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. He presented with low back and left arm pain. The exam reveals pain with range of motion. 
Straight leg raise is positive on the right and left at 35 degrees. There is decreased sensation at L3, L4, L5 
dermatome. Current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. Contraindications include spinal instability, scoliosis, obesity, and osteoporosis. There is 
imaging evidence of convexity of the spine, with no documentation of the Cobb angle. There is no discussion 
indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the request for Vertiflex Superion interspinous device at L4/5 is 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 an interspinous stabilization device.
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 is improving but still require acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH facility. 
 
 
 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 pay for dental services provided by an out-of-network provider on 
February 1, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan 
denied your request. The Plan says the services provided have been processed and paid according to benefit 
rules. 
 
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.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have been met and processed according to the out-of-network benefit rules. 
Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network 
provider on February 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Vabysmo. Our reviewer says that the 
requirements for coverage of Vabysmo have not been met. Our physician reviewer found the Plan requires a 
trial of drug Bevacizumab before they will approve the requested drug. The records show that the enrollee has 
not tried and failed Bevacizumab. There is no documentation provided indicating that Bevacizumab would 
likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.