Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 and D6011) for teeth #3, #8, 
#9, and #14. 
 
You asked the Plan to pre-approve D6010 and D6011. You say that you need this dental work. The Plan denied 
your request. The Plan says the medical criteria for implants have not been met. 
 
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 D6010 and 
D6011 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 D6010 and D6011. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found Tooth #3 (missing) has no 
opposing tooth and would not be a functional replacement. Tooth #8 and #9 is not clearly seen on the supplied x-ray and the status of what appears to be an existing #8 and a missing #9 is not determinable, though the 
provider letter of necessity indicates all sites are viable. Tooth #14 could be a functional replacement. Given 
the current supplied records medical necessity cannot be established at this time. 
 
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 D6010 and D6011 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endosteal implants (D6010 and D6011) for teeth #3, #8, #9, and #14.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from March 29, 2023, 
through March 30, 2023, related to the Transcatheter Aortic Valve Replacement (TAVR) procedure. 
 
You asked the Plan to pay for the inpatient services. You say that the inpatient services should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says the inpatient 
services related to the TAVR procedure are denied because the claim was submitted without a valid clinical 
trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers TAVR under Coverage with 
Evidence Development (CED) when certain conditions are met. The rules also say that it is mandatory to report 
a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED. 
 
We looked at the file and Medicare rules. We confirmed that no clinical trial number was provided on the 
claim, as required for services covered under CED. Based on this information, we decided that Medicare rules 
for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to 
pay for the inpatient services provided from March 29, 2023, through March 30, 2023, related to the 
Transcatheter Aortic Valve Replacement (TAVR) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 8, 2023, billed with 
codes 87635, 87502, 87503, 87486, 87541, 87581, 87651 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was panel testing that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 8, 2023, billed with codes 87635, 87502, 87503, 87486, 87541, 87581, 87651 and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation. 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that your knees are bone on bone. The 
Plan denied your request. The Plan says there is not enough data to support the effectiveness and safety of this 
procedure, or it is not widely used and not generally accepted. 
 
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 a genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. 
 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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing home health visits (G0299x8). 
 You asked the Plan to pre-approve the skilled nursing home health visits. You say that the records provided 
support the need for the services in dispute. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the skilled nursing home health visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the clinical documentation does not specify any changes in plan of care, clinical status changes, changes in 
medication or wound care needs. The records do not show that 8 skilled nursing home health visits are required 
to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
 
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 skilled nursing home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing home health visits (G0299x8).
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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee exceeds established defining 
criteria for a LTACH admission. The Plan denied your request. The Plan says the enrollee does not require 
transfer to a LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically necessary, reasonable, and appropriate. Our 
physician reviewer found at the time of the request for LTACH services, the enrollee's status is stable and 
improving. There are no services available at the LTACH that are not available at the acute care hospital where 
she is currently receiving care.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 a genicular nerve block, 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has pain in both knees, 
but the right side is worse. The Plan denied your request. The Plan says this procedure is 
experimental/investigational. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block,
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on June 1, 
2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary due to the enrollee's health at the time of transport. The Plan denied your request. The Plan says the 
services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergent transport services. Our 
reviewer says that the transport services were not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport were contraindicated for the enrollee. The 
enrollee did not need the expertise, services and life-sustaining equipment that only a fully equipped ambulance 
could provide for a safe transport.  
 
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 non-emergent transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent transport services provided on June 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport services provided on 
May 23, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transport services. You say that the services were 
medically necessary as the enrollee was bed confined and any other means of transportation would have been 
unsafe. The Plan denied your request. The Plan says the services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergent ambulance transport 
services. Our reviewer says that the service was not medically necessary. Our physician reviewer found based 
on the documentation provided, transportation via ambulance from the hospital to the nursing home was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other 
means without endangering the enrollees condition. A prudent layperson would not believe that immediate 
medical attention was required for someone who was being discharged from the hospital. 
 
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 non-emergent ambulance transport services have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergent ambulance transport services provided on 
May 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the clinical 
capabilities of all lower levels of care in the geographical region. You would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 that there are no services at the LTACH that are not available in the current setting, 
and no therapeutic advantage is expected with transfer to the LTACH. 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SI) fusion. 
 
You asked the Plan to pre-approve an SI fusion. You say that the enrollee would benefit from this procedure. 
The Plan denied your request. The Plan says the medical criteria for this procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an SI fusion. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative treatment 
directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine are evident. 
 
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 SI fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SI) fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumococcal conjugate vaccine and administration. 
 
You asked the Plan to pay for the pneumococcal conjugate vaccine and administration. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the pneumococcal 
conjugate vaccine and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the pneumococcal 
conjugate vaccine and administration. Therefore, we decided that the Plan does not have to pay for the 
pneumococcal conjugate vaccine and administration.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
  You asked the Plan to pre-approve SNF care. You say that you need to be in the SNF to regain strength after 
three rounds of chemotherapy. The Plan denied your request. The Plan says SNF care is not medically 
necessary, and your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Remicade infusion therapy provided on April 27, 2023. 
 
You asked the Plan to pay for the Remicade infusion therapy. You say that you have been approved by the Plan 
for the Remicade infusion therapy and have submitted all of the necessary medical records for processing 
payment. The Plan denied your request. The Plan says that the provider did not submit the medication 
administration report with a valid start and stop time and drug dosage that is needed in order to determine the 
clinical utility of the services performed. 
 
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 has not proven outreach was made to the treating provider 
to obtain the requested medical records. Additionally, the Plan has not shown that the medical records provided 
were insufficient to process the claim for payment. Therefore, we decided that the Plan has to pay for the 
Remicade infusion therapy provided on April 27, 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: 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 was seen again by physical therapy, and 
there was a change in status of mobility. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs 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.