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

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
  You asked the Plan to pre-approve additional transportation. You say that the enrollee has a history of three 
strokes causing decreased mobility, speech, and utilizes a wheelchair. You also say that the enrollee is on 
dialysis three times per week and requires transportation. The Plan denied your request. The Plan says as of 
November 16, 2023, the enrollee has received 21 transportations and has had 2 no-shows without giving 24-
hour cancellation notice for a total of 23 trips. The Plan also says that additional trips beyond 24 trips exceed 
the limit of the supplemental benefit. 
 
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 24 one-way non-emergency transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that has, or will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient L3-S1 anterior and posterior 
decompression and fusion (63048 x 2, 22612, 22558, 63047, 22585 x 2, 22614 x 2, 22853 x 3, 22853 x 3, and 
20930). 
 
You asked the Plan to pre-approve the inpatient L3-S1 anterior and posterior decompression and fusion. You 
say that the surgeries are medically necessary. The Plan denied your request. The Plan says the L3-S1 anterior 
and posterior decompression and fusion is not medically necessary. The Plan says there is no documentation of 
smoking cessation counseling or confirmed smoking cessation. 
 
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 inpatient L3-S1 anterior and 
posterior decompression and fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal 
stenosis of the lumbosacral region. The documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There is no clear documentation of a 
trial and failure of formal physical therapy for the lumbar spine. The detailed documentation is not evident 
regarding potential impending/inevitable temporary intra-operative instability. Moreover, he is noted to be a 
current smoker. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested inpatient L3-S1 anterior and 
posterior decompression and fusion 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 inpatient L3-S1 anterior and posterior decompression and fusion have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient L3-S1 anterior and 
posterior decompression and fusion (63048 x 2, 22612, 22558, 63047, 22585 x 2, 22614 x 2, 22853 x 3, 22853 
x 3, and 20930).
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 requires intensive inpatient rehabilitation 
with daily physician management, 24 hour specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge back home. The Plan denied your request. The Plan says based on the available 
information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the 
Medicare rules.  
 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 trachea prosthesis exchange and was discharged home on 12/14/23. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. 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 the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87498, 87502, 
87634, U0003, U0003, 87798, and 87633 for date of service December 14, 2022.  
 
You asked the Plan to pay for the laboratory services as billed. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87498, 87502, 87634, U0003, U0003, 
87798, and 87633 for date of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says the member has not had the previous epidural steroid injection 
three months or longer before a repeat injection. 
 
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 repeat epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has chronic lumbar back pain. The record provided does not document that it has been three 
months since the enrollee's previous injection and does not document with the rationale and medical necessity 
that the enrollee failed to respond well to the initial injection such that a repeat injection after 14 days, using a 
different approach, level and/or medication is appropriate. The elements of the coverage criteria are not 
satisfied.  
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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation services. 
 
You asked the Plan to pre-approve the additional non-emergent transportation services. You say that the 
services are medically necessary for you to get to your appointments. The Plan denied your request. The Plan 
says the services exceed your benefit for the calendar year. 
 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 24 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 additional non-emergent transportation services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve left sided radiofrequency ablation. 
 
You asked the Plan to pre-approve left sided radiofrequency ablation. You say that you had last treatment done 
December 2023 of the right side of your body and need this other treatment due to high amount of pain. The 
Plan denied your request. The Plan says that this does not meet the LCD criteria. 
 
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 left sided radiofrequency ablation. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the request meets the LCD 
criteria and 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 left sided radiofrequency ablation have been met. Therefore, we decided that the 
Plan has to pre-approve left sided radiofrequency ablation.  
 
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 pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no documentation of six weeks of provider directed treatment. 
 
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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found a course of physical therapy has not been 
documented in the submitted records. The request cannot be approved 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on August 24, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the genetic testing by a contract provider. The file does not show that the Plan provided 
notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic testing is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the genetic testing 
provided on August 24, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is 79 years old. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 provided on October 3, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 provided on 
October 3, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam and office visit services provided on 
November 15, 2022. 
 You asked the Plan to pay for the x-ray exam and office visit services. You say that the services were not for 
the enrollee's terminal illness. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the x-ray exam and office visit services provided on 
November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (A4239) on June 24, 2023. 
 
You asked the Plan to pay for supply allowance for nonadjunctive, nonimplanted continuous glucose monitor 
(A4239). You say that you have already submitted medical records along with all the required documents, but 
insurance still denied the claim because of missing/incomplete documents. The Plan denied your request. The 
Plan says the provider is not eligible for payment because they arent enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an 
unassigned claim), a provider or supplier must be enrolled in the Medicare program. You can find this rule in 
42 Code of Federal Regulations (CFR) Section 424.505.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (A4239) have not been met. Therefore, we decided that the Plan does not have to pay for supply allowance for nonadjunctive, 
nonimplanted continuous glucose monitor (A4239) on June 24, 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 cannot walk alone or be safely 
discharged home. They require IRF services in order to get stronger. The Plan denied your request. The Plan 
says the request 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on September 20, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you have not visited nor used your 
dental allowance in years and would like services rendered on September 20, 2023, and September 21, 2023 
reviewed. You also say that you lost a crown and it needed to be replaced. The Plan denied your request. The 
Plan says your benefit for the requested service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The records 
show the Plan had previously processed and paid for procedure D0140 for services rendered on September 20, 
2023, and September 21, 2023 by two other non-participating providers. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation - problem focused (D0140) provided on September 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740) provided on 
March 21, 2023. We also decided that the Plan does not have to pay for the unspecified restorative procedure, 
by report provided on March 21, 2023. 
 You asked the Plan to pay more for the crown. You also asked the Plan to pay for the unspecified restorative 
procedure, by report. You say that your dentist is supporting the services provided based on medical necessity. 
You also say that your fractured tooth caused you pain and frustration when eating and you feel it was 
reasonable to have your tooth repaired. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. The Plan also says per the benefits outlined in your Evidence of Coverage and Quick 
Reference Guide, service D2999 is not covered. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the crown - porcelain/ceramic (D2740) 
provided on March 21, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
restorative procedure, by report (D2999) provided on March 21, 2023.