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

 
We decided that the Plan does not have to pre-approve partial hospitalization. 
 
You asked the Plan to pre-approve partial hospitalization. You say that partial hospitalization is medically 
necessary. The Plan denied your request. The Plan says partial hospitalization is 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 partial hospitalization. Our reviewer 
says that the requested partial hospitalization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that based upon review the records provided for the dates in question was not 
showing any dangerousness to self or others and is not exhibiting any current psychological or psychiatric 
impairment. The enrollee has not been showing any moderate dysfunction in his family, social environment or 
performance of daily living skills. The enrollee was not showing any dangerousness to self or others tolerating 
medication and not showing any perceptual disturbance, psychosis or aggressive behaviors. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care 
rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal 
thoughts or behavioral disturbance.  The health Plans denial of continued partial hospitalization treatment for the dates in question appears 
appropriate. This enrollee did not appear to require partial hospitalization treatment for the dates in question as 
noted above as he was not showing any psychological or psychiatric illness and did not require this intensity of 
treatment. Based upon review the records provided, this enrollee does not meet the criteria for treatment at 
partial hospitalization level of care and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, and was not showing any psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve partial hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (90960) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee changed his Plan and the provider 
he had is no longer in network. The requested visit is necessary for dialysis oversight. The Plan denied your 
request. The Plan says the enrollee does not have out-of-network coverage. This service is available by a 
provider in his network. 
 
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 
an office visit (90960) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions of tooth #1 and 2 (D7210) and does not 
have to pay for a limited oral evaluation (D0140) provided on March 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the denial and cost 
share for these services. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plan's cost-sharing amount when your services are received from an out-of-network 
provider. The Plan also says that your benefit for a limited oral evaluation 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows your benefit for a limited oral evaluation was exhausted on date of service February 24, 2022. 
Therefore, we decided that the Plan does not have to pay more for extractions of tooth #1 and 2 (D7210) and 
does not have to pay for a limited oral evaluation (D0140) provided on March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteotomy services on the first metatarsal. 
 
You asked the Plan to pre-approve osteotomy services on the first metatarsal. You say that the enrollee has a 
right foot hammertoe deformity with plantar deformity. You say that the enrollee has attempted conservative 
treatment with no resolution for her pain. The Plan denied your request. The Plan says the records do not show 
that osteotomy services of the first metatarsal are 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 osteotomy services on the first 
metatarsal. Our reviewer says that osteotomy services on the first metatarsal is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the progress note dated July 1, 2022, 
does not mention or discuss a bunion deformity of the right side.  The progress note dated September 24, 2021, 
advises of a mild bunion deformity. It does not mention or 
discuss pain caused by the bunion deformity, irritation over the first metatarsal head, first metatarsophalangeal 
joint (MPJ) pain, or underlying of the right hallux below the second digit. The medical documentation does not 
support that the enrollee is suffering with pain to their mild bunion deformity. The medical documentation does 
advise that the second digit can be reduced into a correct anatomical position, regardless of the mild bunion 
deformity. Therefore, it is my opinion that the osteotomy services to the first metatarsal right side does not 
conform to medically necessary guidelines and cannot be considered medically reasonable or necessary 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 osteotomy services on the first metatarsal have not been met. Therefore, we 
decided that the Plan does not have to pre-approve osteotomy services on the first metatarsal.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection testing provided on October 
21, 2021, billed with codes 87481, 87640, 87653, 87801, and 12 units of 87798. 
 
You asked the Plan to pay for the testing billed. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says many of these codes are not separately payable. Also, there is no lab report 
provided to support this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 The billed codes have not been supported as the information submitted refers to wellness testing provided on 
August 19, 2021. Based on this information, we decided that Medicare rules for coverage of the testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection 
testing provided on October 21, 2021, billed with codes 87481, 87640, 87653, 87801, and 12 units of 87798.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for twenty-four (24) additional routine 
transportation trips. 
 
You asked the Plan to provide coverage for twenty-four (24) additional routine transportation trips. The Plan 
denied your request. The Plan says the requested amount exceeds the limited listed by the Plan. 
 
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 Plans coverage rules apply in this 
case. 
 
 We looked at your request, the records in the case file, and the rules. The file shows that you requested 
additional routine transportation trips that exceeds the limited listed by the Plan benefit. Therefore, we decided 
that the Plan does not have to provide coverage for twenty-four (24) additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of Neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. This procedure is medically necessary for the enrollee. The Plan denied your 
request. The Plan says this device is still under review for an indication for use in chronic pain management. 
There is insufficient medical literature to support the use of the SPRINT PNS system for chronic neck pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SPRINT PNS system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral 
nerve) (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, captains chair, 
patient weight capacity up to and including 300 pounds (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are requesting an expedited 
grievance for the dneial of your medical power chair. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria as the records show that the enrollee can ambulate household distances 
with a cane. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 standard power wheelchair, captains chair, patient weight capacity up to and including 300 pounds 
(K0823).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation from an emergency clinic to a hospital 
provided on December 30, 2021. 
 
You asked the Plan to pay for the ambulance trip. You say that you required multiple injections of pain 
medications due to the extreme pain you were in. You needed to be transported by ambulance as you were not 
able to sit up in the car or tolerate instability without medication. The Plan denied your request. The Plan says 
that this claim was not billed correctly, and no records were provided to review medical necessity. 
 
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 file does not include evidence that the trip report was requested for this 
denied transportation. In addition, the network status of the transferring or receiving hospital was not indicated. 
The Plan did not show attempts to obtain records from either hospital to allow independent review of whether 
the transportation was medically necessary. The denial of payment is not substantiated in this case. Therefore, 
we decided that the Plan has to pay for the ambulance transportation from an emergency clinic to a hospital 
provided on December 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the enrollee is at high risk for 
developing lymphedema and you believe the use of this device is medically necessary. The Plan denied your 
request. The Plan says There is insufficient literature to establish the requested test as safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve bioimpedance spectroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and cone beam imaging (D0364) 
provided on April 12, 2022. 
 
You asked the Plan to pay for a consultation and imaging. You say that these services were medically 
necessary. The Plan denied your request. The Plan says a consultation (D9310) and cone beam imaging 
(D0364) are not covered by your routine dental benefits. 
 
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 a 
consultation (D9310) and cone beam imaging (D0364) provided on April 12, 2022.
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. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 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.  The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140 x 2), limited oral evaluation (D0140), 
and periapical x-ray (D0220) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the provider's office was in 
your coverage area. You also say that the charges were refused. The Plan denied your request. The Plan says 
the dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the extractions, limited oral evaluation, and periapical x-
ray are not covered under this benefit when received from an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for the extractions (D7140 x 2), limited oral evaluation (D0140), and 
periapical x-ray (D0220) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided on 
February 4, 2022. 
 
You asked the Plan to pay for the F1CDx panel. You say that this was a medically necessary test that was 
required for therapeutic decision making. The Plan denied your request. The Plan says there is no evidence that 
the treating physician ordered this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating 
physician. While lab orders need not be signed, the record must confirm the intent that the testing be provided.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. There is an unsigned requisition form submitted by the provider. No 
progress notes were submitted supporting the intent to perform this testing. The Plan requested records from 
the ordering provider. The office representative indicated that there is no documentation that genetic testing 
was ordered. Without corroboration in the medical record that this testing was ordered and desired by the 
physician, the Medicare coverage criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne CDx (F1CDx) panel provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the incisional biopsy of oral tissue. You say that the enrollee has a lesion 
and should receive the medically needed biopsy. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's benefit package. 
 
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 pre-approve an 
incisional biopsy of oral tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), single bitewing x-ray 
(D0270), 2 retainer crowns (D6740), and 2 pontics (D6245). 
 
You asked the Plan to pre-approve limited oral evaluation and bitewing x-ray. You say that you are having 
trouble eating without your partial. You also say that it needs to be repaired. The Plan denied your request. The 
Plan says the benefit limit for the limited oral evaluation and bitewing x-ray have already been exceeded. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation and bitewing x-ray were exhausted on date of service June 8, 2022. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), 
single bitewing x-ray (D0270), 2 retainer crowns (D6740), and 2 pontics (D6245).