Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute rehab to optimize 
their level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110), complete denture - 
mandibular (D5120) and unspecified removable prosthodontic procedure, by report (D5899) x2 provided on 
December 19, 2022. 
 
You asked the Plan to pay for dental services. You say that you are upset insurance is not covering your 
dentures. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Complete denture - maxillary 
(D5110), complete denture - mandibular (D5120) and unspecified removable prosthodontic procedure, by 
report (D5899) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110, D5120 and 
D5899 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for complete denture - maxillary (D5110), complete denture - mandibular (D5120) and unspecified 
removable prosthodontic procedure, by report (D5899) x2 provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve ablation or injection (64454). 
 
You asked the Plan to pre-approve the genicular nerve ablation or injection. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 or 
injection. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found this service is considered experimental. 
 
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 or injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the genicular nerve ablation or injection (64454).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 1 unit per day for codes B4220 and B4224 for dates of service 
November 12, 2022, to November 17, 2022. We decided that the Plan does not have to pay for the additional 2 
units unit per day for codes B4220 and B4224 for dates of service November 12, 2022, to November 17, 2022.  
 
You asked the Plan to pay for parenteral nutrition billed with codes B4220 and B4224 for dates of service 
November 12, 2022, to November 17, 2022. You say that you have provided medical records to support the 
billing of the parenteral nutrition. The Plan denied your request. The Plan says that these items are never 
covered. 
 
We decided that the Plan has to pay for 1 unit per day for codes B4220 and B4224 for dates of service 
November 12, 2022, to November 17, 2022. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial in this case is that the codes 
billed have a Medically Unlikely Edit (MUE) of 0, meaning that the codes are not covered.  However, the Plan 
has based this denial upon rules which are not applicable in this case.  It appears as though the Plan came up 
with this denial rationale based on the MUE table applicable to physician services.  Parenteral nutrition (such 
as the codes at issue here), are paid under the Durable Medical Equipment (DME) fee schedule, NOT under the 
physician fee schedule.  As a result, it is not appropriate to apply MUE restrictions for physician fee schedule-
based services to DME-based payment items. 
 
Looking at the appropriate DME MUE table, it is clear that codes A4220 and A4224 have a daily MUE value 
of 1. Therefore, we decided that the Plan has to pay for 1 unit per day of parenteral nutrition billed with codes 
B4220 and B4224 for dates of service November 12, 2022, to November 17, 2022.  
  
We also decided that the Plan does not have to pay for 2 additional units per day for codes B4220 and 
B4224 for dates of service November 12, 2022, to November 17, 2022. 
 
 As noted above, the two codes in dispute have a MUE value of 1 per day. However, you have billed 3 units per 
day for codes B4220 and B4224. Only 1 unit per day is allowable, so the Plan cannot be obligated to pay for 
more than that. Therefore, we decided that the Plan does not have to pay for the two additional units per day for 
codes B4220 and B4224 for dates of service November 12, 2022, to November 17, 2022. 
 
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 Sclerotherapy, Left Leg (36470). 
 
You asked the Plan to pre-approve the Sclerotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
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 pre-approve the Sclerotherapy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the patient has not yet undergone 
saphenous vein reflux treatment and the documented diameters of the tributary veins are less than 4mm. 
 
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 Sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Sclerotherapy, Left Leg (36470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left shoulder arthroscopy and rotator cuff repair. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has increased discomfort 
and limited range of motion. The Plan denied your request. The Plan says the enrollee has not tried 
conservative care. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for a muscle strain. Detailed documentation regarding a trial 
and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request. Therefore, the requested left shoulder arthroscopic rotator cuff repair, in this case, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left shoulder arthroscopy and rotator cuff repair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on January 18, 2023, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you were told by the provider that they are in-
network with your plan. You also say that you already got an eye exam and glasses, but received a denial for 
these services. The Plan denied your request. The Plan says this service was rendered by an OON provider, and 
you do not have OON benefits. The Plan also says that they confirmed the provider honors your OON benefits 
in an agreement between you and the office, and the insurance plan is not involved. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92014) provided on January 18, 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the necessary treatment can be provided at the IRF. 
The Plan denied your request. The Plan says the requested IRF admission 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 that 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 you may have a need for physical therapy 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of ondansetron. 
 You asked the Plan to pre-approve the medication. You say that the enrollee has experienced severe nausea. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although ondansetron is an anti-emetic (anti-nausea) drug that is sometimes covered under 
Medicare Part B, the requested use does not fall within Medicare Part B coverage because it is not intended for 
administration with a particular cancer chemotherapy regimen. Therefore, we decided that the Plan does not 
have to pre-approve use of ondansetron.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on Oct 19, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics ran tests, blood work was done and revealed you had very low blood sugar. You were given an 
intravenous saline solution which corrected the issue, and it was determined by the paramedics and your 
husband it was not necessary to go to the emergency room. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
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 19, 2022. 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 with no 
transport provided on Oct 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve an ESI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale* for at least three months. 
 
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 an ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the member did not have 50% pain relief for 
three months.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lumbar epidural steroid injection (ESI) (62323).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ferry services provided on April 20, 2022. 
 
You asked the Plan to pay for the emergency ferry services. You say that you were inside of an ambulance 
received medical care during the entire emergency ferry ride. You also say that the ferry was a necessary part 
of your medical transportation, because the ground ambulance was not capable of transporting you to the 
hospital without using the ferry to transport the vehicle to the mainland. The Plan denied your request. The 
Plan says according to the Evidence of Coverage, the Plan correctly denied payment for the emergency ferry 
transportation. The Plan also says that an air ambulance could have been used in this scenario. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ferry transport services.  
 
 
 The services you have asked the Plan to pay for are ferry transport services. The record shows that the Plan 
confirmed that air ambulance services were an option, and have been called to the location you were 
transported from by ferry in the past. Therefore, we decided that the Plan does not have to pay for the 
emergency ferry services provided on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for conforming bandages (A6446 x 123) and light compression 
bandages (A6449 x 20) provided on October 31, 2022. 
 
You asked the Plan to pay for conforming bandages and light compression bandages. You say that this was 
medically necessary. The Plan denied your request. The Plan says this was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that compression bandages and multi-layer systems are 
only covered when they are used as a primary or secondary dressing over wound(s) that meet the statutory 
requirements for a qualifying wound (surgically created or modified, or debrided). 
 
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 conforming bandages and light compression 
bandages. Our reviewer says that the items at issue are not medically necessary. Our physician reviewer found 
there is no documented evidence of wound caused by, or treated by, a surgical procedure or evidence of 
debridement of the wound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of conforming bandages and light compression bandages have not been met. 
Therefore, we decided that the Plan does not have to pay for conforming bandages (A6446 x 123) and light 
compression bandages (A6449 x 20) provided on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered in patients with acute or 
subacute osteoporotic Vertebral Compression Fracture (VCF) by recent advanced imaging and is either 
hospitalized with severe pain or non-hospitalized with moderate to severe pain despite optimal non-surgical 
management. 
 
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 kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is not an acute or subacute 
osteoporotic VCF, based on symptom onset and documented by advanced imaging. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
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. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to an Inpatient Rehabilitation Facility. 
 
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. 
 
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.