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

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from February 16, 
2023, to February 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee received a medically necessary 
procedure. The Plan denied your request. The Plan says the rules for reimbursement have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. Code 37241 is a device-intensive procedure that was not submitted with the 
required device. The code was not submitted with a modifier to bypass the edit. For this reason, the claim was 
denied as return to provider. A claim returned to the provider means that the provider can resubmit the claim 
once the problems are corrected. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
hospital services provided from February 16, 2023, to February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crown (D6065), 
and pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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. Therefore, we decided that the Plan does 
not have to pre-approve implant supported porcelain/ceramic crown (D6065), and pontic - porcelain/ceramic (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that you need this device because you 
are having trouble sleeping at night. The Plan denied your request. The Plan says 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 you do have 
hypoxemia and hypercapnia, however you do not have documented use or failure of a BiPAP. Also, you do not 
show compelling medical data or documentation to support a home ventilator. Therefore, the best practice is 
you to have a trial of a BiPAP or a BiPAP with AVAPS. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 10, 2023. 
 
You asked the Plan to pay for psychotherapy services (90837). You say that the services at issue were a 
medical necessity 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 psychotherapy services 
(90837) provided on July 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 20, 2023, 
to June 29, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
at the time services were rendered. 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 subsequent nursing 
facility care provided on June 20, 2023, to June 29, 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 the services are medically necessary for the enrollee 
to recieve the care needed. The Plan denied your request. The Plan says the enrollee does 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies, including physical and occupational therapy, 
and an intensive rehabilitation therapy program. The enrollee currently requires maximum assistance for bed 
mobility and transfers as well as toileting and bathing. The enrollee requires minimal assistance with upper 
body dressing and is noted to have good trunk control and be independent with sitting. The enrollee has had a 
significant decline in function and mobility and is actively participating in therapy. The enrollee is weight 
bearing as tolerated in the right lower extremity. The enrollee would benefit from the intensity of therapies 
provided on acute inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 You asked the Plan to pre-approve the injections. You say that you need the injections because nothing else can 
be done to help correct or relieve the pain. The Plan denied your request. The Plan says facet joint injections 
are 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 injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that given the response to your 
prior facet joint injections, there is no documentation provided indicating why you are not a candidate for a 
radiofrequency ablation. Therefore, you do not meet the LCD coverage criteria for additional facet joint 
injections. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481 and 87798) provided on July 12, 
2023. 
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481 and 87798 are not supported in the medical record. Specifically, a panel was 
performed and there is a more appropriate singular code for the services. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the panel testing (87481 and 87798) provided on July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services provided on October 15, 2022, to May 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the enrollee was not in good health at the time of the calls and believe that the services should be covered. The 
Plan denied your request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 15, 2022, to May 27, 2023. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment without transport services provided on October 15, 2022, to May 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no formal shared decision-making interaction with an independent, non-
interventional physician. Additionally, the records show you do not show that the enrollee can have short term 
anticoagulation following the procedure. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
   
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 LAAC. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found while there is reference to consideration of 
the LAAC, there is no documentation of performance of an evidence-based shared decision-making interaction 
on anticoagulation by a non-interventional physician. As such, guidelines would not support implantation of a 
LAAC in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. There is no documentation of a shared 
decision-making interaction. Based on this information, we decided that Medicare rules for coverage of LAAC 
have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
transcatheter closure of the left atrial appendage with endocardial implant (LAAC) (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation provided on May 22, 2023. 
 
You asked the Plan to pay for a telehealth consultation. You say that the enrollee was in a nursing home setting 
at the time the service was rendered. 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 a telehealth consultation 
provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on July 17, 2023. 
 
You asked the Plan to pay for a telehealth visit. You say that the enrollee was in a nursing home at the time the 
service was rendered. 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 a telehealth visit 
provided on July 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on June 26, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided supper the services. 
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 facility 
provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that the enrollee has bilateral 
knee pain that has been present for years. She states the pain is from arthritis. She does report that her knees 
"give out" at times and caused her to fall. She has not been able to find any knee braces that will fit her. She did 
have some steroid injections and Synvisc injections years ago, which helped at 1st but then became ineffective. 
The Plan denied your request. The Plan says this does not meet the criteria for approval. 
 
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 branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve blocks 
are 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0425 and A0428 provide on June 7, 2023. 
 
You asked the Plan to pay for procedure codes A0425 and A0428. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say for ambulance service claims, institutional-based 
providers and suppliers must report an origin and destination modifier for each ambulance trip provided in 
Healthcare Common Procedure Coding System (HCPCS)/Rates. 
 
We find that CPT codes A0425 and A0428 are not supported in the medical record. Specifically, these services 
were billed with an incorrect modifier. These codes were billed with modifier HS. This means that these 
services were for transporting from the hospital to a scene of accident or acute event which would be incorrect 
in this case as the enrollee was transported to their residence. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A0425 and A0428 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes A0425 and A0428 provide on June 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) of the 
blood vessels and grafts of heart with contrast (75574). 
 
You asked the Plan to pre-approve a CTA. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not have cardiac markers obtained and/or an unequivocable exercise stress test. 
 
The Plan follows Medicare rules. Medicare rules say that CTA can be covered when specific criteria are met. 
 
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 CTA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation that the 
electrocardiogram shows an uninterpretable pattern or that you are unable to exercise. 
 
   
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 CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomography angiography (CTA) of the blood vessels and grafts of heart with contrast 
(75574).