Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided on June 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not believe this should be your 
responsibility. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 9, 2023. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2392) provided on June 
30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 6, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that Medicare is not diagnosis-driven, and the 
patient qualifies for this equipment. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that E13.90 has an Excludes1 note in relation to E04.31. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to 
pay for oxygen equipment provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 the laboratory services 
provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections with moderate sedation. 
 
You asked the Plan to pre-approve the moderate sedation. The Plan denied your request. The Plan says that 
moderate sedation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation have not been met. Specifically, the use of moderate sedation with facet 
joint injections is not considered medically necessary. Therefore, we decided that the Plan does not have to pre-
approve facet joint injections with moderate sedation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine study of bone and/or joint whole body. 
 
You asked the Plan to pre-approve nuclear medicine study of bone and/or joint whole body. You say that the 
requested nuclear medicine study of bone and/or joint whole body is medically necessary. The Plan denied 
your request. The Plan says nuclear medicine study of bone and/or joint whole body 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 nuclear medicine study of bone and/or 
joint whole body. Our reviewer says that the requested nuclear medicine study of bone and/or joint whole body 
is not considered medically reasonable and necessary in this case. Our physician reviewer found that a nuclear 
medicine study is not standard of care to assess for osteomyelitis, therefore it is 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 nuclear medicine study of bone and/or joint whole body have not been met. 
Therefore, we decided that the Plan does not have to pre-approve nuclear medicine study of bone and/or joint 
whole body.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve ablation. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that the enrollee has tried every 
conservative treatment including medication management, surgical consults, home exercise program, and 
previous pain injections. The Plan denied your request. The Plan says the genicular nerve ablation 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 the genicular nerve ablation. Our 
reviewer says that the genicular nerve ablation is not medically necessary. Our physician reviewer found that 
the genicular nerve ablation is the subject of ongoing clinical trials and is considered an experimental and 
investigational procedure.  
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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the appropriate care at the 
present acute care hospital. 
 
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 current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on May 23, 2023, to June 16, 
2023. 
 
You asked the Plan to pay for acupuncture services. You say that it is medically necessary. The Plan denied 
your request. The Plan says the enrollee's request for additional acupuncture services exceeding the 20 visits 
per calendar year limitation. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  
 
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 pay for acupuncture services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found acupuncture is not standard of care so 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 acupuncture services have not been met. Therefore, we decided that the Plan 
does not have to pay for acupuncture services provided on May 23, 2023, to June 16, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was admitted to the acute hospital on October 17, 2023, after a fall at home, and his course 
was complicated by acute kidney injury and urinary tract infection. He is now stabilized and is awaiting 
inpatient rehabilitation facility (IRF) placement. Past medical history is also significant for previous stroke with 
chronic right side weakness, coronary artery disease and cardiomyopathy with reduced ejection fraction, and 
prior level of function is noted to have been modified independent at home. He is currently below this baseline. 
The treating team specifically recommended IRF placement to optimize strength, balance, mobility, activities 
of daily living independence, physician management of on-going infection risk and cardio/renal function, and 
ensure a safe return home. 
 
The enrollee's condition is  sufficiently complex, and there is  reason to expect that he will participate in and 
benefit from IRF-level services to include at minimum PT, OT, physician oversight of polypharmacy, and case 
manager coordination of any additional services that might be needed to make a sustainable return home, as 
well as avoid preventable readmissions to the acute hospital. 
 
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 inpatient rehabilitation facility (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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this is the only medication that the office is able to 
buy and bill. You also say that there are no other medications available. The Plan denied your request. The Plan 
says the enrollee has not tried and failed the preferred drugs, Orthovisc, Synvisc/Synvisc-One, or Monovisc. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc, Synvisc/Synvisc-One, or 
Monovisc. The reviewer also found that here is no documentation provided indicating that the Plan's required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer 
found that the step therapy criteria have not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve the HBOT. You say that the enrollee has a history of high dose radiation 
treatment to this area. You also say that this is the recommended HBOT protocol to decrease risk of post-
operative infection and radionecrosis. The Plan denied your request. The Plan says this treatment is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that HBOT may be covered for the treatment of certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the HBOT. Our reviewer says that the 
requested hyperbaric oxygen therapy (HBOT) is not medically necessary. Our physician reviewer found the 
provided documentation indicates that this treatment is being requested with the intent to reduce the risk of one 
of the indications, not for an existing indication. Therefore, the reviewer found that the requested HBOT is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the HBOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure 95937 for date of service June 15, 2023. 
 
You asked the Plan to pay for procedure 95937. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the code billed is 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation submitted 
indicates that train of four testing/monitoring was performed. It is inappropriate to bill the code for 
neuromuscular junction testing for train of four monitoring. Based on this information, we decided that 
Medicare rules for coverage of procedure 95937 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure 95937 for date of service June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services billed with code 99224 for date of 
service November 17, 2022. 
 
You asked the Plan to pay for the observation services. You say that you have provided medical records 
showing that the Place of Service is appropriate. The Plan denied your request. The Plan says you billed the 
wrong Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. In this case, you billed the claim for 
these services with POS code 21.  However, the documentation shows that the patient was in an observation 
status.  Observation is an outpatient status, so POS code 22 should have been used on the claim instead. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the observation services have not been met. Therefore, we decided that the Plan does not have to 
pay for observation services billed with code 99224 for date of service November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says your 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. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least three visits weekly to regain or maintain their 
functional status. There is not a reasonable expectation that this individual will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. The enrollee can receive 
further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete lower dentures 
 
You asked the Plan to pre-approve the lower dentures. You say that you have been having issues with your 
lower dentures because they do not fit right and hurt your gums.  The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete lower dentures
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fiber gelling dressing (A6196), bandage (A6446), and 
tape (A4450) provided on May 26, 2022. 
 
You asked the Plan to pay for the fiber gelling dressing (A6196), bandage (A6446), and tape (A4450). You say 
that the items should be covered. 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 the fiber gelling dressing 
(A6196), bandage (A6446), and tape (A4450) provided on May 26, 2022.