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

 
We decided that the Plan does not have to pay for office visit provided on September 16, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided by an out-
of-network provider on October 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you thought you could go to the dentist in your 
area and would like the claim reviewed. The Plan denied your request. The Plan says your benefit for the 
intraoral radiographic image has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral radiographic image was exhausted on the date of service of July 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided 
by an out-of-network provider on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted evaluation and management services (99499) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve unlisted evaluation and management services. You say that you disagree 
with the denial and request reconsideration. The Plan denied your request. The Plan says you must use network 
providers to receive medical care and services. There are in-network providers available in your Plan that can 
provide the requested service. 
 
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 
unlisted evaluation and management services (99499) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
enrollee does not meet criteria for use of Keytruda. Our physician reviewer found Keytruda is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on May 17, 2022. 
 
You asked the Plan to pay for the oxygen equipment. The Plan denied your request. The Plan says the purchase 
of the portable oxygen concentrator is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The purchase of oxygen equipment is not covered by Medicare or the Plan. 
Based on this information, we decided that Medicare rules have not been met. Therefore, we decided that the 
Plan does not have to pay for the oxygen equipment provided on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbosacral percutaneous vertebroplasty (codes 22511 
and 22512). 
 
You asked the Plan to pre-approve lumbosacral percutaneous vertebroplasty. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbosacral percutaneous vertebroplasty is only 
covered for certain 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 lumbosacral percutaneous 
vertebroplasty. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found you were being treated for age-related 
osteoporosis without current pathological fracture; sacroiliitis not elsewhere classified. You presented status 
post revision lumbo-pelvis in November 2022. (Past surgical history was positive for back surgery for T8-S1 in 
3/2017 with vertebroplasty in October 2016 for 2 of 3 fractures; explant S1 and revision L4 to S1 and S2 and 
iliac instrumentation and fusion on November 17, 2022). The right side feels good. Only the left at the buttock 
region feels painful. The exam reveals pain on palpation of the left sacroiliac joint. The provided 
documentation does not include any acute and/or subacute osteoporotic vertebral compression fracture (VCF) 
at T1-L5. There is no indication of hospitalization or moderate to severe pain that is worsening, with 
progression of vertebral body height loss with a kyphotic deformity. You are under treatment for osteoporosis 
with Prolia. Therefore, you do not meet all of the 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 lumbosacral percutaneous vertebroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lumbosacral percutaneous vertebroplasty (codes 22511 and 
22512).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of SNF care from March 26, 2023, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the continued admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not medically 
necessary after March 26, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you had clinical/functional status change; thus, 
assessment by skilled therapy/nursing would be medically necessary. Clinical documentation shows that 
inpatient skilled therapy goals have been met, no recommendation for frequency of skilled nursing given by 
provider team, but requiring intermittent wound care per documentation; thus, there is no documentation to 
show that you continue to require daily skilled services on an inpatient basis in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of SNF care from March 26, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on November 15, 
2022. 
 
You asked the Plan to pay for the vision service. You say that this service is related to ongoing treatment for a 
stroke from 2021. You say that you appealed this service in 2021 and it was covered. You also say that this provider specializes in treating stroke patients. The Plan denied your request. The Plan says the refraction 
service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam 
 
We looked at the file and the Plan's rules. The provided documentation indicates that the exam in this case was 
medical in nature. Based on this information, we decided that the Plan's rules for coverage of the vision service 
have not been met. Therefore, we decided that the Plan does not have to pay for the refraction service (92015) 
provided on November 15, 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 the member would benefit from an IRF admission. 
The Plan denied your request. The Plan says an IRF admission is not medically reasonable or necessary. 
 
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 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a need for skilled therapy, there is no documented need for intensive rehabilitation 
services. The member can receive further services at a lower level of care. 
 
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 a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (L4-5). (0627T). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the request was denied because this treatment has not been shown in peer-
reviewed literature to be as good as or better than other treatments for back pain due to degenerative disc 
disease. There are Medicare-approved clinical trials studying the efficacy of Via Disc NP in the treatment of 
back pain due to disc disease. The enrollee is not enrolled in an approved study. Injection of viable disc nucleus 
pulposus has not been shown to be a reasonable and necessary intervention for the treatment of discogenic back 
pain. 
 
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 injections. 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 chronic low back pain, without radiation, due to lumbar degenerative disc 
disease. She has tried conservative treatment including, physical therapy, epidural steroid injections, medial 
branch blocks, trigger point injections, and medications without relief. VIA DIisc NP is an off-the-shelf 
processed human nucleus pulposus tissue allograft intended to supplement degenerated intervertebral discs.  It 
is a non-surgical option that can be delivered through a 20G spine needle. The review indicates that the 
provider is requesting the injection of VIA Disc into the spinal disc for advanced degenerative disc disease 
against FDA approval guidelines. Injection of viable disc nucleus pulposus has not been shown to be a 
reasonable and necessary intervention for the treatment of discogenic back pain. Large well-designed studies in 
the peer review scientific literature comparing stand-alone use of VIA Disc to established treatments are 
needed. Published studies do not demonstrate any long-term health outcome advantage with the use of VIA 
Disc NP as an alternative to standard treatments. The review has determined that the services at issue in this 
case are 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (L4-5). (0627T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing, Invitae Charcot-Marie-Tooth Disease 
Comprehensive Panel (81448). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration stating labs 
are needed for the enrollee's medical condition. The Plan denied your request. The Plan says records show that 
the enrollee has polyneuropathy. It is noted that the enrollee has neuropathic pain and foot drop. Based on the 
diagnostic program, MolDX Technical Assessment, the requested test is not an approved test. 
 
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 genetic testing. 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 a history of migraines, polyneuropathy, and Charcot-Marie-Tooth disease. She 
reported recently not having any migraines but has waxing and waning neuropathy and recent falls. She reports 
Lyrica is helping. Based on the diagnostic program, MolDX Technical Assessment, the requested test is not an 
approved test. Also, the request is not medically necessary and does not meet LCD criteria for approval as this 
genetic test will not lead to a significant change in treatment or lead to improvement in function for the enrollee 
as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing, Invitae Charcot-Marie-Tooth Disease Comprehensive Panel (81448).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from March 
22, 2023, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that you were given an injection, so 
they had to make sure you had adequate care. The Plan denied your request. The Plan says the continued stay at 
the psychiatric inpatient hospitalization level of care for this admission is not medically necessary beginning 
March 22, 2023. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient mental health care. Our 
physician reviewer found there is no indication in the available medical records that your psychiatric symptoms 
could not be managed on a less restrictive basis. As of the last covered day, you did not express any active 
suicidal ideation or intent, or any intent to harm yourself or anyone else. You were not exhibiting any other 
significant symptoms such as psychosis or mania. You had no acute psychiatric issues that would require 
continued inpatient care beyond March 22, 2023. You have chronic symptoms. The available medical records 
do not support that continued inpatient care will change these symptoms or your current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from March 22, 2023, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's mileage limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation. The Plan denied your request. The Plan says the requested transportation exceeds the mileage 
limit. 
 
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. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
We looked at your request, the records in the case file, and the rules. We confirmed the requested trip exceeds 
the mileage limit. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's mileage limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. The enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep; this has not 
been shown to fail as an outpatient. Medicare does not cover a home ventilator for the treatment of obesity 
hypoventilation syndrome (OHS), or when used at settings that can be provided with BiPAP. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.