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

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spinal canal and 
contents provided on July 21, 2023. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says documents do not show why the services were needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI was not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
thoracic pain. The record indicates that the enrollee had the requested test in July 2023. The record provided is 
insufficient to establish the medical necessity of the requested test. The requested services were not medically 
necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at that 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance imaging (MRI) of the spinal canal and contents provided on July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service March 30, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the codes were valid for the date of service 
billed. 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 diagnosis code group D12 has an Excludes1 note in relation to K63.5. This 
means that diagnosis codes D12.2 and K63.5 cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for the billed services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88305 billed for date of service March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by a chiropractor on August 18, 2023. 
 
You asked the Plan to pay for the services provided. You say that you were told the provider is in your plan. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that an office visit (code 99202) and electrical stimulation (code G0283) were provided. These 
services are not manual manipulation of the spine. These services are not covered when provided by a 
chiropractor. Therefore, we decided that the Plan does not have to pay for the services provided by a 
chiropractor on August 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that a comprehensive cancer panel was provided. 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. Additionally, the panel test was not billed with a single code as required. 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 the lab services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99235 billed for date of service June 26, 
2023. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the billed code 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 99235 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. 
 
 
 We find that CPT code 99235 is not supported in the medical record. The medical records show that the 
enrollee was admitted on June 26, 2023, and discharged on June 27, 2023. Based on this information, we 
decided that Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99235 billed for date of service June 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide continued SNF care. 
 
You asked the Plan to provide continued SNF care. You say that this is medically necessary. The Plan denied 
your request. The Plan says you have exhausted your 100-day benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from September 9, 2023, 
through December 26, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to provide continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision lenses, the polycarbonate lens, and the anti-
reflective coating provided on September 14, 2023. 
 
You asked the Plan to pay for the single vision lenses, the polycarbonate lens, and the anti-reflective coating. 
You say that you want you $300 benefit to be reinstated. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $300 allowance for non-Medicare-covered eyewear every year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $300 benefit to the eyewear. Based 
on this information, we decided that the Plan's rules for coverage of the single vision lenses, the polycarbonate 
lens, and the anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to 
pay for the single vision lenses, the polycarbonate lens, and the anti-reflective coating provided on September 
14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing faciliy provided on September 01, 2023. 
 
You asked the Plan to pay for skilled nursing faciliy. You say that these services were medically necessary for 
the enrollee. 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 skilled nursing faciliy 
provided on September 01, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services from July 12, 2023, 
through July 25, 2023 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the services for 
the enrollee are not medically necessary and do not meet Medicare criteria for coverage.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 the therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should have been independent with a home exercise program. The Plan says there is no documentation of a 
recent injury or decline in function that was significantly improved with therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the occupational therapy services from July 12, 2023, through July 25, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve collection and application of autologous blood 
concentrate product (D7921), prefabricated abutment - includes modification and placement (D6056) and 
abutment supported porcelain fused to metal crown (high noble metal) (D6059). 
 
You asked the Plan to pre-approve collection and application of autologous blood concentrate product, 
prefabricated abutment - includes modification and placement and abutment supported porcelain fused to metal 
crown (high noble metal). You say that the implant placement is necessary for the enrollee to chew and 
masticate food properly. The Plan denied your request. The Plan says the collection and application of 
autologous blood concentrate product (D7921) and abutment supported porcelain fused to metal crown (high 
noble metal) (D6059) are not covered under this benefit. The Plan also says that prefabricated abutment - 
includes modification and placement (D6056) has 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, the collection and application of 
autologous blood concentrate product (D7921) and abutment supported porcelain fused to metal crown (high 
noble metal) (D6059) are not among those covered under this benefit. The record shows that prefabricated 
abutment - includes modification and placement (D6056) has been exhausted was exhausted on date of service 
March 22, 2023. Therefore, we decided that the Plan does not have to pre-approve collection and application of 
autologous blood concentrate product (D7921), prefabricated abutment - includes modification and placement 
(D6056) and abutment supported porcelain fused to metal crown (high noble metal) (D6059).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left knee radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve the left knee radiofrequency ablation procedure. You say that this procedure 
is medically necessary in order to address the enrollee's chronic knee pain and impaired mobility. The Plan 
denied your request. The Plan says the destruction by neurolytic agent of the genicular nerve is not medically 
necessary. The Plan says the procedure is considered experimental or investigational and has not been proven 
to be beneficial to the enrollee's condition. 
 
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 left knee radiofrequency ablation 
procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee was being treated for pain in the left knee. However, there are limited published, large-scale, long-term peer-reviewed literature which show this request to be an 
effective and/or safe treatment for the noted pathology. This means that further studies are needed to 
corroborate this treatment modality is as safe and effective as other standard treatments for the bilateral knees. 
There is no compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception to guidelines. Therefore, the requested left knee radiofrequency 
ablation procedure 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 left knee radiofrequency ablation procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the left knee radiofrequency ablation procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve transportation services. You say that you are requesting reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the enrollee must receive their 
care from a network provider. 
 
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 
transportation services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to crown 
(D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown (D2954). You say that 
you are appealing this denial. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 prefabricated post and core in 
addition to crown (D2954) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve the prefabricated post and core in addition to crown (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230), resin-based 
composite (D2391), and treatment of root canal obstruction (D3331) provided on March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that it is your understanding that an additional 
payment of $1,560 is to be paid to the provider. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. The Plan also say that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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 annual maximum allowable benefit for the services was exhausted on date of service March 23, 
2023. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray 
(D0230), resin-based composite (D2391), and treatment of root canal obstruction (D3331) provided on March 
23, 2023.
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 needs three hours of physical therapy a 
day and also needs to see a physician daily. 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. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is 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, but the services 
required can be provided 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: 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 medical records provided explain the reason for 
the IRF request. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval and are 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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
pneumonia and anemia. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. 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. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care (99291) provided on June 27, 2023. 
 
You asked the Plan to pay for the physician service. You say that if this is a Medicare policy, this should be 
overturned based on the CMS guidelines for timely filing being one year after the date of service. The Plan 
denied your request. The Plan says the claim was not filed within one year of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician service was not filed until September 12, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the critical care (99291) provided on June 27, 2023.