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

 
We decided that the Plan does not have to pay for an annual wellness visit provided on July 10, 2023. 
 
You asked the Plan to pay for an annual wellness visit. You say that you should not have to pay for a billing 
mistake. The Plan denied your request. The Plan says that you had a previously billed annual wellness exam 
that was billed on January 18, 2023. The claim processed correctly as maximum benefit exceeded as this 
service was rendered within the calendar year. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on July 10, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital admission with inpatient services provided from 
June 15, 2023, to June 28, 2023. 
 
  You asked the Plan to pay for the hospital admission with inpatient services. You say that you would like 
payment to be reconsidered based on medical necessity treatment. The Plan denied your request. The Plan says 
the enrollee currently has another insurance with their spouse with an effective date of June 18, 2022, and is 
currently active. The Plan also says in order to process the claim the Explanation of Benefits (EOB) from the 
primary other insurance is need, but has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the 
EOB from the enrollee's primary insurance multiple times with no success. As the secondary insurer, the Plan 
cannot be held responsible for the hospital admission with inpatient services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the hospital 
admission with inpatient services provided from June 15, 2023, to June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure to L5-S1. 
 
You asked the Plan to pre-approve the Intracept procedure to L5-S1. You say that the enrollee's primary issue 
is chronic low back pain due to degenerative disc disease that has resulted in the development of vertebrogenic 
pain identified by degenerative endplates. You say the enrollee has failed non-operative treatment and the 
Intracept procedure is the only solution. The Plan denied your request. The Plan says the Intracept procedure is 
not medically necessary. The Plan says the enrollee has chronic lower back pain due to the presence of non-
vertebrogenic pathology that can explain the source of pain.  
 
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 Intracept procedure to L5-S1. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is being treated for spondylosis without myelopathy or radiculopathy. 
The enrollee presents with left buttock and hip pain. In this case, there are multiple plausible pathologic sources 
of significant pain generation. The documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being 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 the Intracept procedure to L5-S1 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Intracept procedure to L5-S1.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says that the coverage criteria has not been met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our
Medical Director states that the enrollee in this case does not meet criteria for continued coverage of IRF. The
enrollee is generally medically stable, and the documentation does not support that he has complex medical
issues that require continued acute rehab nursing care or monitoring by an inpatient physical medicine and 
rehabilitation physician three times per week. While the enrollee is reasonably expected to benefit from
continued physical and occupational therapy, the documentation does not support that there is need for an
intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. Our Medical Director found that the enrollee's condition does
not meet Medicare criteria for IRF 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 for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bifocal lenses rendered on March 13, 2023.

You asked the Plan to pay for these services. You say that the Plan denied your request. The Plan says the
claim was 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 up to $300 per year to help pay for eyewear and contact lenses.

We looked at the file and the Plan's rules. The file shows that you received bifocal lenses on March 13, 2023.
The previous determination stated that the Plan did not provide documentation that you used your full $300
supplemental benefit; however, the file clearly shows that the Plan applied the full $300 benefit to this claim.
The provider charged $390 total and the Plan applied a 20 percent discount on your remaining balance of $90,
leaving you with a remaining balance of $72. Further payment is not covered by your supplemental benefit or
Medicare. Therefore, we decided that the Plan does not have to pay for the bifocal lenses rendered on March
13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on March 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
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 G0483 is drug testing, definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
match the date of service billed. 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 lab services 
(G0483) provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left genicular nerve radiofrequency ablation (RFA) 
(64624). 
 
You asked the Plan to pre-approve the RFA. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the current medical literature does not consider this service to be standard 
medical treatment for your 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 RFA. Our reviewer says that the 
requested genicular nerve RFA is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental for knee pain. Therefore, the reviewer 
found that the requested genicular nerve RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve left genicular nerve radiofrequency ablation (RFA) (64624).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown - porcelain fused to metal, tooth #24, #26 (D6751), 
pontic - porcelain fused to metal, tooth #25 (D6241). 
 
You asked the Plan to pre-approve retainer crowns and pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers retainer 
crowns and pontic when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve retainer crowns and pontic. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the documentation 
provided indicates that tooth #25 is/was extracted due to infection. It is medically reasonable and necessary to 
place a fixed bridge to replace the missing #25. A single missing anterior tooth is best replaced by a fixed 
bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crowns and pontic have been met. Therefore, we decided that the Plan 
has to pre-approve retainer crown - porcelain fused to metal, tooth #24, #26 (D6751), pontic - porcelain fused 
to metal, tooth #25 (D6241).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival flap procedure, including root planing (D4241) and 
dental implant removal (D6100) provided on July 20, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
flap procedure, including root planing (D4241) and dental implant removal (D6100) provided on July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara device. 
 
You asked the Plan to pre-approve a Volara device. You say that the enrollee has significant lung disease. You 
say that the enrollee cannot use certain devices. You also say that this device is compatible and easier to use. 
The Plan denied your request. The Plan says this is not covered for home use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Volara device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Volara device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full series x-rays (D0210) provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 July 28, 2021. Therefore, 
we decided that the Plan does not have to pay for full series x-rays (D0210) provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with ophthalmic diagnostic 
imaging provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for the vision services. You say that you do not agree with the 
copayment assessed for the office visit. 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 $35 
copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care. 
 
 You have been asked to pay a $35 copayment for the vision services. This service falls within vision care 
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 waive the copayment for the office visit with ophthalmic 
diagnostic imaging provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination provided on June 16, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye examination. You say that the Plan denied for no authorization. 
You say you want the documentation reviewed and to be paid accordingly. The Plan denied your request. The 
Plan says the provider is out-of-network, and the service was not referred by 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 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 did not pre-approve the 
medical eye examination. We found no exception that would require the Plan to pay for the medical eye 
examination. Therefore, we decided that the Plan does not have to pay for the medical eye examination 
provided on June 16, 2023, by an out-of-network (OON) provider.
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 the services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan.  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial for your 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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
considered experimental therapy. It is the subject of ongoing clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance (64624).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.