Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the physical therapy services. You say that you would like 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 
physical therapy services to be provided OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA testing (81479) provided on July 6, 2023. 
 
You asked the Plan to pay for the PrismRA testing (81479). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that this test is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. In addition, this test was reported with the correct unique identifier 
and CPT code. Based on this information, we decided that Medicare rules for coverage of PrismRA testing 
have been met. Therefore, we decided that the Plan has to pay for the PrismRA testing (81479) provided on 
July 6, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular artery embolization with ultrasonic 
guidance. 
 
You asked the Plan to pre-approve the genicular artery embolization with ultrasonic guidance. You say that the 
procedure is medically necessary to treat the enrollee's condition and will provide a long-lasting pain relief that 
will improve the enrollee's quality of life. The Plan denied your request. The Plan says the genicular artery 
embolization with ultrasonic guidance 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 artery embolization with 
ultrasonic guidance. Our reviewer says that the genicular artery embolization with ultrasonic guidance is not 
medically necessary. Our physician reviewer found that the genicular artery embolization with ultrasonic 
guidance is the subject of ongoing clinical trials and is considered experimental 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 genicular artery embolization with ultrasonic guidance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the genicular artery embolization with 
ultrasonic guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 19, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on September 19, 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 had a syncopal episode when they woke 
up and their family is concerned with them going home, and requested that the enrollee go to rehab to get 
stronger. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does 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 this enrollee 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion in a home setting (96413, 96415). 
 You asked the Plan to pre-approve home health services. You say that you are in need of home infusion which 
you were getting every 6 weeks for 10 years. You are in a lot of pain and cannot wait until February 2024 to 
see your rheumatoid specialist. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you have a 
past medical history of multiple medical comorbidities including rheumatoid arthritis. Clinical documentation 
does not specify any provider order for medication/infusion or face to face visit designating you as "home 
bound" therefore not medically necessary or appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve infusion in a home setting (96413, 96415).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Nalu Neurostimulation system. 
 
You asked the Plan to pre-approve Nalu Neurostimulation system. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Nalu Neurostimulation system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found this condition meets the Food and Drug Administration (FDA) product 
labeling. Temporary peripheral nerve stimulation (PNS) provided good pain relief. The permanent placement 
of a PNS is medically reasonable and 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 Nalu Neurostimulation system have been met. Therefore, we decided that the 
Plan has to pre-approve Nalu Neurostimulation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services and an annual 
wellness visit provided on August 14, 2023. 
 
You asked the Plan to pay for the transitional care management services and an annual wellness visit. You say 
that you are requesting reconsideration of the denied claim. 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 transitional care 
management services and an annual wellness visit provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture visits provided on August 4, 2023, to 
September 8, 2023, by an OON provider. 
 
You asked the Plan to pay for the acupuncture visits. You say that you do not know how much worse you need 
to get to have your bills covered. The Plan denied your request. The Plan says the services were provided by an 
OON provider without written approved prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the acupuncture visits provided on August 4, 2023, to September 8, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve amniotic membrane placement. 
 
You asked the Plan to pre-approve amniotic membrane placement. You say that the enrollee needs this 
procedure due to having multiple diagnosis affecting their corneas. The Plan denied your request. The Plan 
says an amniotic membrane placement 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 amniotic membrane placement. Our 
reviewer says that an amniotic membrane placement is not medically necessary.  Our physician reviewer found 
that the enrollee has dry eyes associated with filamentary keratitis, epithelial basement membrane dystrophy, 
punctate keratitis, and keratitis sicca. However, there are no documented prior failure of more than one class of 
conservative treatment for dry eyes, which usually includes lubricating drops, gels, ointments, cyclosporine or 
lifitegrast, topical non-steroidal anti-inflammatory and steroid drops, and punctal plugs. The enrollee has mild 
dry eye and proceeding to amniotic membrane placement is not medically reasonable without prior failure of 
multiple classes of conservative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of amniotic membrane placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve amniotic membrane placement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the diagnostic mammogram services, and 
the laboratory services provided on August 29, 2023. 
 
You asked the Plan to waive the copayments for the diagnostic mammogram services, and the lab services. 
You say that the services should be fully covered as preventative. 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 $50 
copayment for each covered x-ray service, including diagnostic mammogram. Your contract with the Plan also 
clearly says that you must pay a $10 copayment for each covered laboratory service. 
 
You have been asked to pay a $50 copayment for the diagnostic mammogram services. You have also been 
asked to pay a $10 copayment for the lab services. This item/service falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. You have been asked to pay a total of $60 ($50 
copayment + $10 copayment = $60). 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 copayments for the diagnostic 
mammogram services, and the laboratory services provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3, per sq cm. 
 
You asked the Plan to pre-approve Kerecis Omega3. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not clearly show the enrollee has adequate 
circulation to the heel to justify this procedure such as a recent normal ankle brachial index (ABI) measurement 
or normal vascular flow study. Therefore, without sufficient support made for this request, the Kerecis Omega3 skin substitute will be considered not medically necessary 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3, per sq cm.
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 meets full criteria for an IRF admission. 
The Plan denied your request. The Plan says IRF care 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 patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records proving 
medical necessity. 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 an office visit provided 
on October 09, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94640 billed for date of service March 19, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the code is payable under Medicare guidelines. The 
Plan denied your request. The Plan says the code is not separately payable. 
 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 code 94640 is not supported. Code 94640 has a Q1 status indicator. No separate payment is 
made for this service when billed with a code that has a status indicator of V, such as billed code 99284. Based 
on this information, we decided that Medicare rules for coverage have not been met.  Therefore, we decided 
that the Plan does not have to pay for procedure code 94640 billed for date of service March 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320 and D3310) for teeth #29 
and #7, 
 
You asked the Plan to pre-approve D3320 and D3310. You say that you need this dental work. The Plan denied 
your request. The Plan says the requested dental services are not covered benefits. 
 
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 pre-approve 
endodontic therapy (D3320 and D3310) for teeth #29 and #7,