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

 
We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve RFAs. You say that you need these shots to relieve the pain you have in 
your spine. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint RFAs may be covered if certain criteria 
have been 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 RFAs. Our reviewer says that you do 
not meet criteria for the requested radiofrequency ablations. Our physician reviewer found metastatic cancer 
pain is not treated with facet blocks. In order to treat facet mediated pain, two sets of diagnostic blocks should 
produce greater than 80% pain relief each. This has not been achieved; therefore, this request is deemed not 
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 RFAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations (RFAs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that it is medically necessary to 
receive the transportation to your appointments. The Plan denied your request. The Plan says the benefit has 
been exhausted. 
  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional transportation trips.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve D6056. You say that you need this service. The Plan denied your request. 
The Plan says that this conflicts with the services the Plan approved. 
 
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 D6056 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 D6056. Our reviewer says that the 
requested service is medically reasonable and necessary. Our physician reviewer found tooth #13 has been 
extracted and is the only missing tooth in the maxillary arch. A prefabricated abutment is needed to support the 
crown and meets the criteria for coverage. 
 
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 D6056 have been met. Therefore, we decided that the Plan has to pre-approve a 
prefabricated abutment (D6056).  
 
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 pre-approve a medical eye exam (92004) with an ophthalmologist to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a medical eye exam. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. Treatment can be safely rendered in-network. 
 
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 
a medical eye exam (92004) with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure oral nutrition supplements. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that orally administered enteral nutrition products, related 
supplies and equipment will be denied non-covered, no benefit. 
 
We looked at the file and Medicare rules. The services at issue are Ensure oral nutrition supplements. Orally 
administered enteral nutrition is denied by Medicare as non-covered. Therefore, we decided that the Plan does 
not have to pre-approve Ensure oral nutrition supplements.
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 you need this support and help after being 
discharged from the hospital. The Plan denied your request. The Plan says your condition does not meet all of 
the requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower level 
of care.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is 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: 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 you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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. 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. Given there are offered alternatives, LTACH is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu, Prochlorperazine, Alteplase recombinant, 
Diphenhydramine, Methylprednisolone sodium succinate. 
 
You asked the Plan to pre-approve Enhertu, Prochlorperazine, Alteplase recombinant, Diphenhydramine, 
Methylprednisolone sodium succinate. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Enhertu, Prochlorperazine, Alteplase 
recombinant, Diphenhydramine, Methylprednisolone sodium succinate. Our reviewer says that the services are 
not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No 
literature from Medicare approved cancer journals were submitted for review. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu, Prochlorperazine, Alteplase recombinant, Diphenhydramine, 
Methylprednisolone sodium succinate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Enhertu, Prochlorperazine, Alteplase recombinant, Diphenhydramine, Methylprednisolone sodium 
succinate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88341-26-XU billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for code 88341-26-XU. You say that this code was billed with the XU modifier, so it 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 27, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 88341-26-XU have not been met. 
Therefore, we decided that the Plan does not have to pay for code 88341-26-XU billed for date of service 
March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrophysiologic study and intracardiac catheter 
ablation. 
 
You asked the Plan to pre-approve an electrophysiologic study and intracardiac catheter ablation. You did not 
provide a specific argument with your appeal request. The Plan denied your request. The Plan says this 
procedure is not indicated for the patient's condition based on current medical literature. The records do not 
show that the patient has failed treatment with antiarrhythmic medications or that there is documentation of a 
premature ventricular contraction (PVC) burden that is greater than 15% in the patient's cardiac event monitor 
studies. 
 
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 an electrophysiologic study and 
intracardiac catheter ablation. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found at issue is the appropriateness and medical 
necessity of catheter ablation in the treatment of a patient who was evaluated for palpitations in July of 2023. 
His subsequent ambulatory electrocardiogram (ECG) monitoring showed a PVC burden of under 10%. He was 
started on an antiarrhythmic drug, with reported improvement in his palpitations at an office visit in August of 
2023.  At the current time, based on current guidelines as well as the records provided, catheter ablation of 
PVCs is not medically necessary in this patient. 
 
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 electrophysiologic study and intracardiac catheter ablation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electrophysiologic study and 
intracardiac catheter ablation.
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 would benefit from an IRF admission. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for an IRF admission. 
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  The enrollee can receive further services 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36561, 77001, 76937, 
and 99152. We decided that the Plan does not have to pay for the services described by procedure code(s) 
99153.  
 
You asked the Plan to pay for procedure codes 36561, 77001, 76937, 99152, and 99153 provided on April 21, 
2023. You say that you would like the Plan to reconsider their denial of payment. The Plan says that the 
services are not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 36561, 77001, 76937, 
and 99152.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 36561, 77001, 76937, and 
99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan must follow Medicare rules. The rules say Technical Component (TC) Only Codes identify stand- 
alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests 
for which there is an associated code that describes the professional component (PC) of the diagnostic test only. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Indicator of 3, which specifies a Technical Component 
only code. Therefore, we decided that the Plan does not have to pay for the services described by procedure 
code(s) 99153. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging performed 
on June 27, 2023. 
 
You asked the Plan to waive the copayment for a myocardial perfusion imaging. You say that you are unable to 
afford to pay the cost share applied due to a limited income. 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 $200 
copayment for advanced radiology services.  
 
 
  You have been asked to pay a $200 copayment for a myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests 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 a 
myocardial perfusion imaging performed on June 27, 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's current medical condition requires an 
IRF level of care. The Plan denied your request. The Plan says the IRF services requested do not meet the 
criteria 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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. 
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.