Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 27, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 an office visit provided 
on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on June 27, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter 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 to pay for the PrismRA test. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the provided records in this case indicate 
the PrismaRA test was ordered due to a significant number of swollen joints on exam. The enrollee also was reported to have received much benefit from Humira and the Humira was working better than 
methotrexate. The treatment plan was to continue Humira and methotrexate. Provided records did not clearly 
document what drug(s) were being considered as an alternative to the Humira and methotrexate and for what 
indication(s) to ensure that the test performed was reasonable and necessary as is required by the LCD. 
 
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 PrismRA test have not been met. Therefore, we decided that the Plan does 
not have to pay for the PrismRA test (81479) provided on June 27, 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 LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH 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 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 patient is presently receiving appropriate services in the acute care setting. The 
provided records do not explain what care services will be provided in the LTACH that are not available in the 
present hospital setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation 
facility or a skilled nursing facility. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services 
provided on August 29, 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 meets Medicare criteria and will benefit 
from Acute Inpatient Rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the records do not show the enrollee needs to be seen by a rehabilitation physician three 
times per week and has no complex wound care. 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic services provided on January 25, 2022. 
 
You asked the Plan to pay for orthopedic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the claim must be submitted within 1 year from date 
of initial determination/redetermination for any reason. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for orthopedic services was not filed until June 30, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for orthopedic services provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 02, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that this testing was medically necessary. 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 laboratory testing 
provided on June 02, 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 LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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's medical needs are being met at the current care setting. Documentation 
does not support that LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the nerve blocks. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this procedure is not supported by research and is not covered. 
 
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 nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are 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 the nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular nerve blocks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 372321 rendered from July 2, 2023 to July 5, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37231 is "Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and 
atherectomy, includes angioplasty within the same vessel, when performed." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that CPT 37231 is used to indicate the 
performance of atherectomy in a tibial (or peroneal) artery and stenting of the same artery. In this case, the 
documentation does not demonstrate that atherectomy was performed to a tibial (or peroneal) artery, nor does it 
demonstrate that tibial (or peroneal) stenting was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 372321 rendered from July 2, 2023 to July 5, 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 needs IRF services to optimize their 
level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval of the requested IRF services.  
 
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's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on August 25, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that the CGM was medically 
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM and related supply allowance. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the record 
provided does not indicate that the enrollee is being treated with insulin or has problematic hypoglycemia as 
defined by the Medicare rules. The elements of the coverage criteria are not satisfied. The requested service is 
not 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 the CGM and related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on August 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 01, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were told that 
you would not have to pay for this service. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance services 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 the 
ambulance transportation provided on July 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images 
(D0210), the intraoral radiographic image (D0220), and the adjunctive pre-diagnostic test (D0431) provided on 
June 27, 2023. You asked the Plan to pay for the dental services. You say that you went to a new dentist, and you got a notice 
from the Plan that the x-rays were not covered. The Plan denied your request. The Plan says your benefit for 
the intraoral complete series of radiographic images and the intraoral radiographic image has already been 
exhausted. Also, the adjunctive pre-diagnostic test is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on November 16, 2021; therefore, your 
benefit for the intraoral complete series of radiographic images (D0210) was exhausted on the date of service 
of November 16, 2021. The Plan paid for an intraoral radiographic image (D0230) on June 27, 2023; therefore, 
your benefit for the intraoral radiographic image (D0220) was exhausted on the date of service of June 27, 
2023. The adjunctive pre-diagnostic test is not covered under the Plans dental benefit. Therefore, we decided 
that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210), the 
intraoral radiographic image (D0220), and the adjunctive pre-diagnostic test (D0431) provided on June 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve 8 chiropractic manipulative treatments. The Plan denied your request. The 
Plan says the only covered chiropractic service is manual manipulation of the spine to correct subluxation.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  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 8 chiropractic manipulative treatments 
Our reviewer says that 8 chiropractic manipulative treatments is not medically necessary. Our physician 
reviewer found that the enrollee has thoracic and lumbar pain and spasm. However, the records do not 
document the presence of subluxation either by physical examination or radiographic images. Also, the records 
do not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. Therefore, the elements of the coverage criteria are not satisfied, and the requested service is not 
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 8 chiropractic manipulative treatments have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 8 chiropractic manipulative treatments.