Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot walk around on your own, take care of yourself, live alone or eat and drink properly. You say that you need constant help and need three hours of therapy to get your strength back and start caring for yourself. The Plan denied your request. The Plan says admission to IRF was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Your needs can be met at skilled nursing facility, with home health at home with supervision, in an assisted living facility with home health, with parttime skilled services in long-term care.

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 you are currently living at home and receiving home health services. You have been experiencing increasing weakness with increasing falls, one of which required assessment in the emergency department on August, 23, 2022. In the past you were ambulating with a walker and required some assistance with daily activities, including dressing, bed mobility and transfers. Currently you require minimal assistance with dressing, transfers and bed mobility. There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.

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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments on tooth #4, 5, 6, 8, 9, 12, and 14 
(D6057) and abutment supported crowns on tooth #4, 5, 6, 8, 9, 12, and 14 (D6059). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says custom abutments (D6057) and abutment supported crowns (D6059) 
are not covered by your 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 pre-approve 
custom abutments on tooth #4, 5, 6, 8, 9, 12, and 14 (D6057) and abutment supported crowns on tooth #4, 5, 6, 
8, 9, 12, and 14 (D6059).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0480) provided on February 23, 2022.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier Q0 or Q1 must be used when billed 
with diagnosis codes V70.7 and Z00.6 for clinical trial services. 
 
We looked at the file and Medicare rules. In this case, the clinical trial services were billed with diagnosis code 
Z00.6. As such, modifier Q0 or Q1 is required for payment to be considered. 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 (G0480) provided on February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need admission to the IRF. The Plan denied your 
request. The Plan says that based on Medicare guidelines, the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that you have active conditions that will require close medical 
monitoring on an inpatient basis. Evaluating therapists, both physical and occupational, recommend intense 
therapy and state you can tolerate three hours of therapy per day. Our reviewer also found the lumbar stenosis 
with weakness and neurogenic claudication is an IRF compliant diagnosis and is medically necessary 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve block. 
 
You asked the Plan to pre-approve a nerve block. You say that a nerve block is medically necessary. The Plan 
denied your request. The Plan says the requested nerve block does not meet the Medicare LCD coverage 
criteria. 
 
The Plan follows Medicare rules. 
 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 nerve block. Our reviewer says that a 
nerve block is not medically necessary. Our physician reviewer found that genicular nerve blocks and genicular 
nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of 
chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis 
of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a 
treatment for individuals who are not candidates for knee replacement surgery. The requested genicular nerve 
block is not reasonable and 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 a nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a nerve block.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services (A0242, A0425) 
provided on March 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency ambulance services by an out-of-network provider. You say that 
the service was medically necessary. The Plan denied your request. The Plan says it was not an emergency, and 
the provider was out-of-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 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 non-emergency ambulance services (A0242, 
A0425) provided on March 25, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports the services. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the 
requested service have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
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 placement of an ILR. Our reviewer says 
that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found 
that, while the enrollee has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope or any other apparent indication for an ILR. There is insufficient 
documentation to support the medical necessity for insertion of an ILR in the enrollee's clinical management. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an ILR.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panniculectomy. 
 
You asked the Plan to pre-approve a Panniculectomy. You say that this surgery is medically necessary due to 
how low the skin hangs, rashes and a hernia. The Plan denied your request. The Plan says Medicare coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 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 Panniculectomy. Our reviewer says 
that Medicare coverage criteria are not met. Our reviewer found the medical records and photos provided 
indicate you are requesting to have skin removed and to have your abdominal wall repaired. The requested 
procedure is for a panniculectomy surgery to remove excess skin from the lower abdomen to be performed by 
Plastic Surgery. There is no request for abdominal wall repair at this time from the physician. The review 
indicates that based on the medical records provided, the surgery does not qualify as a medical procedure as 
opposed to a cosmetic procedure. Therefore, Medicare coverage criteria are not met.  
 
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 Panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77002, 27369) provided on November 18, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly.  
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, code 27369 must be reported in 
conjunction with code 73580, 73701, 73702, 73722, or 73723. As one of these codes has not been billed, code 
27369 is not payable. We have also confirmed that code 77002 is an add-on code and has not been billed with 
an appropriate primary procedure code. As the billed primary code is not payable, the add-on code is also not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (77002, 27369) provided on November 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the criteria for inpatient coverage are not met. Our physician reviewer found the enrollee is 
being treated for unilateral primary osteoarthritis of the knee. She is approved for a total knee arthroplasty. The 
documentation does not show a significant past and/or current medical history that would place her at increased 
risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
record does not show that an admitting physician may reasonably expect that the enrollee's necessary hospital 
care (including earlier ED and/or observation care) will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for tendon sheath incisions performed May 3, 
2021, and May 17, 2021. 
 
You asked the Plan to waive the copayments for tendon sheath incisions. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $400 for tendon sheath incisions ($200/surgery x 2). A tendon sheath incision falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for tendon sheath incisions performed May 3, 
2021, and May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3421), retrograde filling (D3430), 
and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243). 
 
You asked the Plan to pre-approve the apicoectomy, retrograde filling, and sedation/analgesia. The Plan denied 
your request. The Plan says these services are not covered under your benefit plan. 
 
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 
apicoectomy (D3421), retrograde filling (D3430), and intravenous moderate (conscious) sedation/analgesia 
(D9239 and D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of benign tumor or cyst of mandible (21040) 
and a bone graft of mandible (21215). 
 
You asked the Plan to pre-approve the excision of benign tumor or cyst and bone graft. You say that these 
services are medically necessary to relieve the enrollee from pain and restore them back to normal function. 
The Plan denied your request. The Plan says no documentation was provided to indicate the presence of a 
tumor and/or cyst, or that this infection was related to anything other than the absence of dental hygiene. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an excision of benign tumor or cyst of 
mandible (21040) and a bone graft of mandible (21215). have been met. Medical records were not provided 
with this case. The records show that the Plan requested medical records, but they were not provided. Without 
this information, we are unable to determine if these services are medically necessary. Therefore, we decided 
that the Plan does not have to pre-approve an excision of benign tumor or cyst of mandible (21040) and a bone 
graft of mandible (21215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted teeth- soft tissue (D7220). 
 
You asked the Plan to pre-approve removal of impacted teeth. You say that you need this service. The Plan 
denied your request. The Plan says this service is not covered under your 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 pre-approve 
removal of impacted teeth- soft tissue (D7220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on November 10, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial of this claim. You have 
submitted medical records to show proof of medical necessity. The Plan denied your request. The Plan says the 
requested provider is not a participating provider with the Plan. The enrollee does not have out of network 
benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on November 10, 
2021, by an out-of-network (OON) provider.