Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 60 routine transportation trips. 
 
You asked the Plan to pre-approve an additional 60 routine transportation trips. You say that you need 
transportation to get to medical appointments. The Plan denied your request. The Plan says you have utilized 
the maximum number of transportation trips allowed per year. 
 
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 a maximum of 30 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 60 routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 1, 2021 to September 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF care. You say that the services should be covered. The Plan denied your 
request. The Plan says the claim denied correctly. 
 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 did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from September 
1, 2021 to September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing for 1 to 3 teeth per quadrant 
(D4342) and scaling and root planing for 4 or more teeth per quadrant (D4341) provided on December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that this is a financial hardship for you. The Plan 
denied your request. The Plan says the dental reimbursement maximum of $200 has been reached. The Plan 
also says that additional reimbursements are not covered. 
 
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 maximum reimbursement amount 
of $200 has been exhausted. The record shows that the Plan paid $200 towards Therefore, we decided that the Plan does not have to pay for the scaling and root planing for 1 to 3 teeth per quadrant (D4342) and scaling and 
root planing for 4 or more teeth per quadrant (D4341) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on August 11, 2021. 
 
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 a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of B under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services. No separate payment can be made for the anesthesia services (99100). 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 the services (99100) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing is medically necessary. The Plan denied 
your request. The Plan says labs related to ESRD treatment are included in payment to the dialysis facility. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple myeloma fluorescence in situ hybridization 
(FISH) analysis (88291, 88261, 88275, 88271, 88264, 88262, 88280). 
 
You asked the Plan to pre-approve the genetic testing services. You say that this genetic testing service is 
medically reasonable and necessary for managing the enrollee's condition. The Plan denied your request. The 
Plan says the requested services are not medically reasonable and necessary as ordered. 
 
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 genetic testing services. 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 myeloma diagnosed in 2017, currently status 
post-transplant. The enrollee is currently on polmolidomide and decadron with free kappa light chains 
increasing and you are worried about progression. In this case, molecular testing will not aid in the treatment 
plan for myeloma. If the patient's condition is progressing, the National Comprehensive Cancer Network 
guidelines for myeloma clearly lay out treatment approoach irrespective of molecular studies. 
 
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 genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve multiple myeloma fluorescence in situ hybridization (FISH) analysis (88291, 
88261, 88275, 88271, 88264, 88262, 88280).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve occipital injection services. 
 
You asked the Plan to pre-approve occipital injection services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says that this procedure is not 
covered because it is not better than standard treatments for this type of headache. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 occipital injection services. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee is a 78-year-old woman who has occipital neuralgia. She is 
taking Celebrex and gabapentin for pain.  She has had physical therapy and osteopathic manipulative treatment. 
She received a Left Greater Occipital Nerve block and achieved greater than 80% pain relief for 2 months. The 
request is to repeat the block. Occipital neuralgia is a distinct entity from cervicogenic headache. Occipital 
nerve block with steroids is a well-established therapy for occipital neuralgia and is medically reasonable and 
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 occipital injection services have been met. Therefore, we decided that the Plan 
has to pre-approve occipital injection services.  
 
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 outpatient psychotherapy services provided to the enrollee on 
June 17, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider must attempt to consult the attending or primary care physician about the 
services furnished and document the consent or declination date to consultations, and the date of consultations 
in the patients medical record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy services provided to the 
enrollee on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET) scan of the 
skull base to mid-thigh. 
 
You asked the Plan to pre-approve the PET scan services. You say that this PET scan is medically reasonable 
and necessary for managing the enrollee's condition. The Plan denied your request. The Plan says the criteria 
for coverage for the PET scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan services. Our reviewer 
says that the requested PET scan is not medically reasonable and necessary. Our physician reviewer found the 
enrollee was diagnosed with stage III Diffuse large B cell lymphoma and completed chemotherapy on April 13, 
2020. In this case, the PET scans for surveillance of diffuse large B-cell lymphoma is not a standard of care and 
not supported by the National Comprehensive Cancer Network Guidelines. This patient has had 3 PET scans 
with no evidence of disease since completion of chemotherapy. The service is 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 the PET scan services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the positron emission tomography (PET) scan of the skull base to mid-thigh.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autonomic nervous system function testing (95923 and 
95924) provided on October 7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the autonomic nervous system function testing. You say that you would like 
reconsideration because these services were medically necessary. The Plan denied your request. The Plan says 
no necessity for an out-of-network provider, such as an urgent or emergency situation has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the autonomic nervous system function testing 
(95923 and 95924) provided on October 7, 2021 by an out-of-network (OON) provider.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically 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 was admitted for non-surgical management of a tibial 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 enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64640). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the procedure is experimental and non-
covered. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found radiofrequency ablation of the sacroiliac joint is considered an 
investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64640).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the semi-electric hospital bed is not medically necessary. Our physician reviewer found the 
medical record does not support the need for frequent or immediate changes in body position. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
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 requested IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity 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 you are medically stable and do not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. At the current functional level, you do not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy 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: 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 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 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 while the enrollee may benefit from physical and occupational therapy, the enrollee's 
rehabilitation can be safely provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. Documentation does not support the necessity for admission to 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: 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 a medical necessity for the enrollee. The 
Plan denied your request. The Plan says medical necessity 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 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, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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.