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

 
We decided that the Plan does not have to pre-approve a genicular nerve injection. 
 
You asked the Plan to pre-approve genicular nerve injection. You say that the enrollee is in constant pain. The 
Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
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 genicular nerve injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve injections are considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for periodic oral evaluation, intraoral x-rays, and cleaning (D0220, D0230, D0120, D1110) provided on April 3, 2023.

You asked the Plan to pay more for the dental services. You say that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for periodic oral evaluation, intraoral x-rays, and cleaning (D0220, D0230, D0120, D1110) provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1852, L2397), provided on May 10, 2023. 
 
You asked the Plan to pay for the knee brace. You say that the items should be covered. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no mention in the records of any knee pain or instability, or the need for knee bracing. The problem list in the medical record does not list knee pain or arthritis as one of the enrollee's diagnoses and there 
was no specific physical examination of the knee. There is no commensurate note in the medical record on or 
around the date of order as to why the brace was being ordered. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the knee brace (L1852, L2397), provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tetanus, diphtheria, and pertussis vaccination (Tdap) and 
its administration on May 3, 2023. 
 
You asked the Plan to pay for the vaccination. You say that you believe the Plan should pay for the vaccination 
because it was part of your office visit. The Plan denied your request. The Plan says that this vaccination is 
covered under your Part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccination. 
Therefore, we decided that the Plan does not have to pay for a Tetanus, diphtheria, and pertussis vaccination 
(Tdap) and its administration on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on April 13, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the injection services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 injection services provided on April 13, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 23, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 office visit provided on March 23, 2023, by an 
OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the SNF admission. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. However, you do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter mitral valve repair (TMVR). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure is considered experimental and unproven for the enrollee's diagnosis.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of bioprosthetic mitral valve placed in 2012, with recent evidence 
of mitral stenosis and regurgitation. The use of TMVR in the setting of prosthetic valve malfunction is 
considered investigational, and not the standard of care, for this condition. As a result, at this time TMVR 
would not be considered medically reasonable and necessary in this enrollees 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter mitral valve repair (TMVR).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has tried and failed all 
reactive attachment disorder (RAD) therapies and is in great need of a ventilation system die to no 
improvement in arterial blood gas (ABG). The Plan denied your request. The Plan says that a home ventilator 
is not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD and central sleep apnea with documented failure of a BiPAP and CPAP. The enrollee requires more 
support from a home ventilator because their central sleep apneas has worsened their 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 a home ventilator system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omalizumab (J2357). 
 
You asked the Plan to pre-approve Omalizumab. The Plan denied your request. The Plan says the information 
received does not support chronic spontaneous urticaria or no known underlying cause of chronic urticaria as it 
is stated that urticaria is contact and cholinergic related. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Omalizumab. Our reviewer says that 
Omalizumab is not medically reasonable and necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of contact urticaria precipitated by heat, alcohol, and recent pregnancy. The FDA 
has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the 
Medicare approved 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. Our physician reviewer also 
found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Omalizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Omalizumab (J2357).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 63276 and 99223 for date of service February 4, 2023. 
 
You asked the Plan to pay for codes 63276 and 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 63276 is laminectomy for biopsy/excision of intraspinal 
neoplasm; extradural, thoracic. The CPT Code Manual definition of code 99223 is initial hospital inpatient or 
observation 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, 75 minutes must be met or exceeded. 
 We find that CPT codes 63276 and 99223 are not supported in the medical record. Specifically, the submitted 
medical records do not include a detailed procedure note for laminectomy for biopsy/excision of intraspinal 
neoplasm; extradural, thoracic; therefore, code 63276 cannot be verified. The medical records do not include 
the total time spent on the date of the encounter. A total time of 75 or more minutes must be documented for 
this code to be supported; therefore, code 99223 cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of codes 63276 and 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 63276 and 99223 for date of service February 4, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99999. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 99215.  
 
You asked the Plan to pay for procedure codes 99215 and 99999 provided on February 7, 2023. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that payment is included in the 
global surgery payment. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99999.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99999.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99215. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code 99215 is included in the global surgery 
payment for procedure code 20605 provided on February 7, 2023. Separate payment cannot be made for 
procedure code 99215. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99215 have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 99215. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor (E0651) and segmental 
appliance (E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compressor and segmental appliance . You say that the item 
is medically necessary. The Plan denied your request. The Plan says there are in-network providers available 
that can provide this item. 
 
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 
the pneumatic compressor (E0651) and segmental appliance (E0667) to be provided 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 you need to continue therapy services and would like 
to go to an IRF. The Plan denied your request. The Plan says you do not meet the criteria for admission to an 
IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker purchased on December 26, 2022. 
 
You asked the Plan to pay for the walker. You say that the item should be covered. The Plan denied your 
request. The Plan says Durable Medical Equipment (DME) is not reimbursable through your wellness wallet 
benefit as that is a Medicare covered item. You purchased the item through a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The plan will reimburse members for certain services not covered by 
Original Medicare. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program and is not covered under the wellness wallet benefit as it is a Medicare covered item. Therefore, we 
decided that the Plan does not have to pay for the walker purchased on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
(D7250) provided on November 22, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that you were unable to locate an in-
network dentist. You also say that you called the customer service representative and was given this provider to 
call and schedule the extraction. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for simple extractions/surgical extractions  allowed one per tooth per lifetime.  
 You have been asked to pay a 20% coinsurance for the removal of residual tooth roots. This service falls within 
the dental services 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 pay for the removal of residual tooth roots 
(cutting procedure) (D7250) provided on November 22, 2022.