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

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439) and periodic 
comprehensive preventive medicine reevaluation and management (99397) provided on July 14, 2023. 
 
You asked the Plan to pay for the physician services. You say that you had one physical. You say that this was 
not billed correctly. You say that the provider advised they would fix it. You also say that you feel you are 
entitled to the physical and the claim is the responsibility of the provider. The Plan denied your request. The 
Plan says the benefits for these services have been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
Based on review of the file, an AWV and annual physical exam were provided less than 12 months prior to the 
visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit 
(G0439) and periodic comprehensive preventive medicine reevaluation and management (99397) provided on 
July 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the review 
indicates that the requested visits are custodial, which is unskilled care that provides assistance with activities 
such as eating, dressing, bathing and toileting. You and/or your caregiver are able to manage her activities of 
daily living, such as bathing, grooming, and dressing without the assistance of a home health aide. The review 
has determined that the services do not meet the definition of home health aide services as per Sections A, B, 
C, D & E of Section 50.2. The home health aide services are not reasonable and necessary to the treatment of 
your illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide.
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 enrollee's medical condition will vastly continue 
to deteriorate without an inpatient level of rehabilitation. You say the enrollee requires peritoneal dialysis 
which skilled nursing facilities cannot handle. The Plan denied your request. The Plan says the request 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the upper spinal canal. 
provided on August 09, 2023. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI) of the upper spinal canal.. You say that you 
are requesting reconsideration. 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 magnetic resonance 
imaging (MRI) of the upper spinal canal. provided on August 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the lumbar spine. 
provided on June 14, 2023. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI) of the lumbar spine.. You say that you would 
like reconsideration based on the records submitted. 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 magnetic resonance 
imaging (MRI) of the lumbar spine. provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99306-25 and 99070 provided on August 10, 2023. 
 
You asked the Plan to pay for 99306 and 99070. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says code 99306 was billed within the global period of 11042 and the use of 
-25 is not supported, and 99070 has a Status Indicator of B so is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 99306 and 99070. Our reviewer says that code 99306 does 
not meet criteria for payment. Our reviewer found the documentation does not support initial nursing facility 
evaluation and management. There is a more appropriate code that could be used. 
 
We find that procedure code 99070 has a Status Indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99306 and 99070 have not been met. Therefore, we decided that the Plan does 
not have to pay for codes 99306-25 and 99070 provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown for teeth 22, 23 and 27 (D6751); and a 
pontic for teeth 24, 25 and 26 (D6241). 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says to approve a bridge, the member must be missing only one upper front 
tooth or only two lower front teeth. The two lower front teeth must be next to each other. The member also 
cannot be missing any of his or her back teeth. Our dentist looked at the x-rays and said the member are 
missing other teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers retainer 
crown and pontic when the services are medically necessary and reasonable.  
 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 retainer crown and pontic. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found due to the enrollees number of 
missing teeth, there are other treatment options that could address a greater need for the enrollee. The enrollee 
is stating that he is biting into gums, and this will not be solved with a dental bridge for the front. The enrollee 
is needing to replace his back missing teeth and this condition can cause him to be over closed causing trauma 
to gums. Based on the information provided, there is not enough to make the determination that D6241 (pontic-
porcelain fused to metal) for teeth #24,25,26 and D6751 (retainer crown-porcelain fused to metal) for teeth 
#22,23,27 is medically reasonable or necessary due the other conditions that are noted in the enrollees mouth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown for teeth 22, 23 and 27 (D6751); and a pontic for teeth 24, 25 
and 26 (D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot billed for date of service June 7, 2023. 
 
You asked the Plan to pay for the billed item. You say that you only billed the claim one time. The Plan denied 
your request. The Plan says an appropriate modifier indicating a replacement was not billed. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee received a walking boot, coded L4361, in March 2023. The enrollees current 
walking boot serves the same purpose as the item at issue. Plans may determine the reasonable useful lifetime 
of equipment, but in no case can it be less than 5 years. Therefore, we decided that the Plan does not have to 
pay for the walking boot billed for date of service June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ganglion nerve block. 
 
You asked the Plan to pre-approve a ganglion nerve block. The Plan denied your request. The Plan says a 
ganglion nerve block 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 a ganglion nerve block. Our reviewer 
says that a ganglion nerve block is not medically necessary. Our physician reviewer found that the 
documentation did not show a finding of at least two of the following of an involved digit or extremity 
including any of the following: allodynia or hyperalgesia; edema; skin color asymmetry; sweating asymmetry; 
skin temperature asymmetry; trophic changes; decreased range of motion or motor dysfunction. Also, the 
medical records did not show if the medicine the enrollee was prescribed at their last visit was tried and 
whether it worked or not, and there are no notes regarding any of her physical therapy appointments, or how 
many visits she had.  Therefore, a ganglion impar block is considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ganglion nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ganglion nerve block.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 07, 2023, to August 21, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that they accepted Medicare and did not consider if 
they were in-network. 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 physical therapy 
provided on August 07, 2023, to August 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on July 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim is not a duplicate. The Plan denied 
your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I70.92, defined as 
chronic total occlusion of artery of the extremities. This code is not an appropriate primary diagnosis as the 
code has a Code first note indicating to code the underlying condition first. Based on this information, we 
decided that Medicare rules for payment have not been met. Therefore, we decided that the Plan does not have 
to pay for the ambulance transportation provided on July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not show the enrollee requires services at the LTACH that are not already 
available.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 you had fell and sustained injuries to your face and 
had multiple rib fractures. You say that you are recovering from muscle breakdown while laying on the floor 
for 12 hours and have spent a week in the hospital where you attempted to get transferred to an acute care rehab 
but was denied. You say that you were told that you have to got to a skilled nursing facility where you will be 
transferred soon, but feel that they will not be able to manage your medical problems properly. The Plan denied 
your request. The Plan says an IRF admission 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says criteria for coverage are not 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TECENTRIQ. 
 
You asked the Plan to pre-approve TECENTRIQ. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for coverage. 
 
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 TECENTRIQ. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records indicate that the enrollee has a 
diagnosis of extensive stage small cell lung cancer. The record indicates that the enrollee has had progression 
following previous anti- PDL-1 receptor therapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TECENTRIQ have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TECENTRIQ.