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

 
We decided that the Plan does not have to pay for the influenza virus vaccine (90662) and the administration of 
the influenza virus vaccine (G0008) rendered by the out-of-network (OON) provider on October 22, 2021. 
 
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the item/service was 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 item/service 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 this item/service. Therefore, we decided 
that the Plan does not have to pay for the influenza virus vaccine (90662) and the administration of the 
influenza virus vaccine (G0008) rendered by the out-of-network (OON) provider on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic osteogenesis stimulator rendered on February 
26, 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 the services were not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that an osteogensis stimulator is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a right foot fracture. 
There is no documentation of a minimum of two sets of radiographs, obtained prior to starting treatment with 
the osteogenic stimulator, separated by a minimum of 90 days. The criteria for coverage are not  met; therefore, 
the services were not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasonic osteogenesis stimulator rendered on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve a facet joint radiofrequency ablation. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a 
time period, which includes all procedures (i.e., MBB, IA, facet cyst ruptures, and RFA ablations) that are 
performed during the same day. 
 
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 facet joint radiofrequency ablation. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the request is for 
three levels of the spine to be treated on the same day. The Medicare LCD criteria were not met as the request 
is to treat more than two levels on the same day. 
 
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 facet joint radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a facet joint radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the diabetic shoes and inserts provided on November 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that your provider told you they would be 
covered. The Plan denied your request. The Plan says that there are limitations to the items provided. 
 
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. 
 
We looked at the file and the rules. In this case, there is no claim information or medical records to show that 
the enrollee previously received diabetic shoes and inserts within the calendar year. The items were provided 
by a contract provider. The file does not show that the Plan provided notice that the items would not be 
covered. Under Medicare rules, this means the items are considered approved by the Plan. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the diabetic shoes and inserts provided on 
November 17, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on July 19, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on July 19, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on October 22, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 8, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by an out-of-network provider on 
November 20, 2021. 
 
You asked the Plan to pay for a crown. You say that you believe the dentist's behavior shows a rip-off for 2021. 
The Plan denied your request. The Plan says the maximum benefit allowance amount of $1,500 has been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum allowance amount of $1,500 for combined dental services.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the maximum benefit allowance 
amount has been exhausted. Based on this information, we decided that the Plan's rules for coverage of a crown 
have already been met. Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided 
by an out-of-network provider on November 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hormone replacement therapy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that in-network providers are unable to prescribe the doses you need in a cream. The Plan denied your request. The Plan says the requested services are available with a contracted 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve hormone replacement therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network acupuncture visits provided 
from September 5, 2021, to October 28, 2021. 
 
You asked the Plan to waive the copayment for the out-of-network acupuncture visits. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 a $70 
copayment for Acupuncture for chronic low back pain Covered services.  
 
 
  You have been asked to pay a $70 copayment for each acupuncture provided from September 5, 2021, to 
October 28, 2021. 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 to waive the copayment for out-of-network acupuncture 
visits provided from September 5, 2021, to October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial rotation unit (L5986). 
 
You asked the Plan to pre-approve a multiaxial rotation unit. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested 
item have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have been approved for a multiaxial ankle with swing phase active dorsiflexion. A 
multiaxial ankle with swing phase active dorsiflexion serves the same purpose as a multiaxial rotation unit. 
Therefore, we decided that the Plan does not have to pre-approve a multiaxial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve the RFA services. You say that the injection services are medically 
necessary for the enrollee who is in a lot of pain. You say that the clinical notes provided support the requested 
procedure. The Plan denied your request. The Plan says the requested RFAs do not meet Medicare criteria for 
coverage. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are covered when 
they are considered medically reasonable and necessary for patients who meet specific criteria. 
 
  
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 RFA services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has both axial low 
back pain and radicular pain. She underwent diagnostic medial branch blocks (MBBs) on one side on January 
3, 2022, and then the other on January 27, 2022. The enrollee only achieved 50-60% pain relief. Therefore, the 
requested RFA sessions are not considered 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 RFA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH 
admission criteria and is needed in order to sustain a safe and sustainable discharge. The Plan denied your 
request. The Plan says LTACH care 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 the enrollee appears to be more stable but requires short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. 
Transfer to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be 
considered when treatment has completed. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for liver biopsy services provided to the enrollee on October 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code cannot be verified. 
 
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 47100 is "Biopsy of liver, wedge." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report describes a 
laparoscopy for cholecystectomy, and a liver wedge biopsy. There is no procedure code for a laparoscopic liver 
wedge biopsy. In this case, the biopsy should be reported with an unlisted procedure code, as a 
cholecystectomy and a liver biopsy are two separate procedures. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for liver biopsy services provided to the enrollee on October 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy in your home (G0152 x 5). 
 
You asked the Plan to pre-approve occupational therapy visits. You say that your balance is still off. You say 
that you are having mobility issues. You also say that the services are medically necessary. The Plan denied 
your request. The Plan says the requested home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 occupational therapy visits. Our 
reviewer says that the requested occupational therapy visits are not medically necessary. Our physician 
reviewer found the documentation does not support that you require additional skilled occupational therapy 
services to provide treatment that is medically necessary. The reviewer found that you do not require additional 
occupational therapy services to effectively provide treatment, care, and/or services in order to improve your 
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The 
reviewer found that you have been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. Therefore, the reviewer found that the requested occupational therapy visits are 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve occupational therapy in your home (G0152 x 5).
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 unable to return home due to lack of 
support. You say that you live alone and will have limited mobility following surgery, creating difficulty 
managing activities of daily living. The Plan denied your request. The Plan says the records do not show that 
the enrollee has a need for daily skilled nursing services or daily skilled therapy services. The Plan says that the 
services needed can safely be received at a different setting. 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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. While the enrollee does require skilled therapy services, they are not 
required on a daily basis. The enrollee is walking household distances with a rolling walker with supervision or 
set-up assistance and is supervision or set-up assist for transfers. The provided records do not document a 
significant decline in the enrollees functional status to necessitate daily inpatient skilled therapy services. 
There is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document that services in the home with home health care or in a long-term care 
facility on a part-time basis are not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.