Persius/hicric huggingface dataset:
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 needs rehabilitation services. The Plan 
denied your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert device (A9280). 
 
You asked the Plan to pre-approve a life alert device. You say that you recently had a fall and were unable to 
get off the floor till the next morning. You need this device so you can call for help when needed. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a telephone alert system are emergency 
communication systems and do not serve a diagnostic or therapeutic purpose.  
 
While an alert system may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a life alert device (A9280).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image 
guidance, includes placement of intra-articular implant(s) (0775T). 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant(s). You say that this is medically necessary. The Plan denied your request. 
The Plan says this is not medically necessary because the records do not show the enrollee has had 2 diagnostic 
sacroiliac joint injections with two different anesthetics with two different durations of action. 
 
The Plan follows Medicare rules. 
 
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 arthrodesis, sacroiliac joint, 
percutaneous, with image guidance, includes placement of intra-articular implant(s). Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found the LCD requires 2 sets of blocks 
with different anesthetic agents. This was not done and therefore, the 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 arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant(s) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-
articular implant(s) (0775T).
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 enrollee needs the long-term care 
facility to regain maximum function. The Plan denied your request. The Plan says the enrollee's records do not 
show do not show that the care required can only be given in a hospital setting. Services needed may be 
provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current 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 radiofrequency ablation (RFA) for the sacroiliac joint 
(SIJ). 
 
You asked the Plan to pre-approve RFA for the SIJ. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this service is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint (SIJ) denervation (also called 
radiofrequency ablation or RFA) is not considered reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA for the SIJ have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) for the sacroiliac joint (SIJ).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutritional therapy (97803). 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have a covered diagnosis for this 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutritional therapy (97803).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TENS unit supplies (A4556, A4557, A4630) provided on 
June 12, 2022. 
 
You asked the Plan to pay for the TENS unit supplies. You say that these supplies are not medically necessary. 
The Plan denied your request. The Plan says you are appealing the denial with supporting medical records. The Plan follows 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 pay for the TENS unit supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that TENS for low back pain is excluded unless the enrollee is enrolled in an 
approved clinical trial. The enrollee is not enrolled in an approved clinical trial and therefore, the request was 
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 the TENS unit supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the TENS unit supplies (A4556, A4557, A4630) provided on June 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there was system issue beyond 
your control. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for You asked the Plan to pay for an office visit provided out-of-
area (OOA) on December 1st, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the enrollee's denied services. The 
Plan denied your request. The Plan says the service is not covered because prior approval was not obtained.  
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 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 an office visit. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there were no issues that met the definition of 
urgent or emergency 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 an office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for You asked the Plan to pay for an office visit provided out-of-area (OOA) on December 1st, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for an insertion of a drug-
delivery implant (11981) provided on January 16, 2023. 
 
You asked the Plan to pay for assistant at surgery services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for an 
insertion of a drug-delivery implant (11981) provided on January 16, 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 these services are medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in other settings.  
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 21, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90833) and office visit (99214) provided 
on January 02, 2023. 
 
You asked the Plan to pay for the psychotherapy (90833) and office visit (99214). 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 the psychotherapy 
(90833) and office visit (99214) provided on January 02, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 19, 
2022, to June 17, 2022. You asked the Plan to pay for the billed services. You say that the NOA was submitted. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 19, 2022. The NOA was not received by the Plan until May 25, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service May 19, 2022, to June 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar spine the MRI without dye.

You asked the Plan to pre-approve the lumbar spine MRI. You say that you do not want to wait longer for the MRI because your condition is worsening. The enrollee stays they tried physical therapy, but it did not resolve the problem. The Plan denied your request. The Plan says the lumbar MRI is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the lumbar spine MRI. Our reviewer says that the lumbar MRI is not medically necessary. Our physician reviewer found the enrollee has left foot pain, bilateral leg weakness. The enrollee was diagnosed with arthritis of the foot and has a history of cervical spinal stenosis. The documentation did not show that initial testing for the leg weakness such as a more complete physical/neurological examination or conservative treatment with physical therapy was fully exhausted before considering advanced imaging. There was no evidence of a red flag diagnosis on presentation according to the provided documentation. Therefore, this request for MRI lumbar spine 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 the lumbar spine MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar spine MRI without dye.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), a comprehensive oral evaluation 
(D0150), and periapical X-Rays (D0220 and D0230) provided from March 22, 2023, to March 28, 2023. 
 
You asked the Plan to pay for dental services. You say that you were told that dental services were covered. 
The Plan denied your request. The Plan says gingival irrigation is not covered by the Plan and you already 
exhausted the benefits for comprehensive oral evaluation and periapical X-Rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among 
those covered under this benefit. You received a covered comprehensive oral evaluation on April 16, 2021; 
therefore, the benefit was exhausted at the time this service was performed. You received 2 covered periapical 
X-Rays on March 22, 2023; therefore, the benefit was exhausted at the time these services were performed. 
Therefore, we decided that the Plan does not have to pay for gingival irrigation (D4921), a comprehensive oral 
evaluation (D0150), and periapical X-Rays (D0220 and D0230) provided from March 22, 2023, to March 28, 
2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve procedure codes L5828, L5848, and L5856. We decided that the 
Plan does not have to pre-approve procedure code L5859. 
 
You asked the Plan to pre-approve a standard microprocessor knee described by codes L5828, L5848, and 
L5856 and an endoskeleton knee-shin system described by code L5859. You say that you disagree with the 
denial. The Plan says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve procedure codes L5828, L5848, and L5856 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic attachments are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for these services. Our reviewer says that procedure 
codes L5828, L5848, and L5856 are medically necessary and code L5859 is not medically necessary. Our 
physician reviewer found that the requested non-powered microprocessor knee is the basic standard of care for 
the enrollee's condition and is reasonable and medically necessary at this time, as the records clearly document 
a K3 ambulator status.  There is no physical examination nor discussion of a past medical history that supports the enrollee needs or qualifies for a knee with the extra power feature. The physician note from April of 2023 documents the enrollee 
has full strength throughout the remaining anatomy in both legs. The extra power feature is not reasonable or 
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 procedure codes L5828, L5848, and L5856 have been met. Therefore, we 
decided that the Plan has to pre-approve the standard microprocessor knee described by codes L5828, L5848, 
and L5856.  
 
We also decided that the Plan does not have to pre-approve procedure code L5859. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that code L5859 is not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
L5859 have not been met. Therefore, we decided that the Plan does not have to pre-approve the endoskeleton 
knee-shin system described by code L5859. 
 
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.