Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the therapy services. You say that this facility was recommended to you by 
your primary provider. You also say that you have tried three other in-network facilities that cause you more 
pain. The Plan denied your request. The Plan says that these services can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341), and full mouth debridement to enable a comprehensive periodontal evaluation and 
diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve the dental services represented by codes D4341 and D4355. You say that 
you disagree with the denial and would like the Plan to reconsider coverage. The Plan denied your request.  The Plan says your benefit for the periodontal scaling and root planing - four or more teeth per quadrant and 
full mouth debridement 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 record 
shows your benefit for the periodontal scaling and root planing - four or more teeth per quadrant and full mouth 
debridement was exhausted on date of service January 17,2023. Code D4355 lists service conflicts with 
previous service in your history, Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - four or more teeth per quadrant (D4341), and full mouth debridement to enable a 
comprehensive periodontal evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the portable oxygen equipment 
provided on December 16, 2022. 
 
You asked the Plan to increase the reimbursement for the oxygen equipment. You say that you would like more 
reimbursement for the equipment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 25% coinsurance for out-of-network durable medical equipment. 
 
 
 The enrollee has been asked to pay $9.13, which is 25% coinsurance of the allowed amount for the oxygen 
equipment ($36.52 x 25% = $9.13). The record shows the enrollee should only be reimbursed $27.39 ($36.52 
allowed amount - $9.13 coinsurance = $27.39). This item/service falls within the durable medical equipment 
and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to increase the reimbursement for 
the portable oxygen equipment provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service January 3, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that this code should be paid separately. The 
Plan denied your request. The Plan says procedure code 99140 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service January 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided on September 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the encounter was coded correctly. The Plan 
denied your request. The Plan says that code 77049 is not recognized by the outpatient prospective payment 
system. 
 
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 denied the claim at issue due to procedure code 77049 not being recognized as payable. The 
remaining codes were denied as coding errors need to be corrected first. However, the claim submitted did not 
include procedure code 77049. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the outpatient hospital services provided on September 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to base metal crowns (D2751), pontic - 
porcelain/base metal (D6241), and retainer crown (D6751). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or 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 record 
shows your benefit for the requested item or service was exhausted on date of service July 5, 2022. Therefore, 
we decided that the Plan does not have to pre-approve porcelain fused to base metal crowns (D2751), pontic - porcelain/base metal (D6241), and retainer crown (D6751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781) and photochromatic tint 
(V2744) provided on December 9, 2022. 
 
You asked the Plan to pay for the progressive lens and photochromatic tint. You say that you paid $130 
because the doctor refused to examine you without paying first. You also say that no one told you that you 
would have a copay. The Plan denied your request. The Plan says there is a $30.00 copayment for each covered 
upgrade in addition to the copayment for the glasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 We looked at the file and the Plan's rules. The contract clearly states that there is a $30.00 copayment for each 
covered upgrade in addition to the copayment for the glasses. The progressive lens and photochromatic tint are 
considered upgrades, and you are responsible for a $60 copayment in total for these services. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens and photochromatic tint have 
not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens (V2781) and 
photochromatic tint (V2744) provided on December 9, 2022.
Appeal type: Drugs
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 you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 the enrollee has chronic bilateral knee pain due to osteoarthritis. The enrollee has 
been treated with medications including, opiates and corticosteroid injections. Knee replacement surgery has 
been recommended. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is needing to go to a rehabilitation center 
for a higher level of care. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met at an alternate 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 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 IRF admission and services.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan must waive $25 per day of the copayment applied for a SNF stay provided from 
January 6, 2023, to February 7, 2023. We decided that the Plan does not have to waive $125 per day of the 
copayment applied for a SNF stay.  
 You asked the Plan to waive the copayment for a SNF stay provided from January 6, 2023, to February 7, 
2023. You say that you were not advised of how much you would be required to pay. The Plan says that the 
cost sharing applied is correct. 
 
We decided that the Plan must waive $25 per day of the copayment applied for a SNF stay.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan has applied a cost share of $150 copayment per 
day for days 21 to 100; However, your contract states you must pay a $125 copayment for days 21 to 100. 
Therefore, we decided that the Plan must waive $25 per day of the copayment applied for a SNF stay provided 
from January 6, 2023, to February 7, 2023.  
 
We also decided that the Plan does not have to waive $125 per day of the copayment applied for a SNF 
stay. 
 
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 $0 
copayment for days 1 to 20 and a $125 copayment for days 21 to 100. Therefore, we decided that the Plan does 
not have to waive $125 per day of the copayment applied for a SNF stay provided from January 6, 2023, to 
February 7, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from 3 hours of therapy 5 
days a week. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee's needs can be met at an alternate 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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed . You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from July 28, 2022, to August 26, 
2022. 
 You asked the Plan to pay for home health care. You say that you successfully submitted the Notice of 
Admission (NOA) which was accepted by the Plan. The Plan denied your request. The Plan says the denial of 
payment for this claim is correct. 
 
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 July 28, 2022. The NOA submitted indicates a creation date of December 7, 
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 home health care provided 
from July 28, 2022, to August 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 You asked the Plan to pre-approve Synvisc-One. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc-One. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of pain in right knee. The documentation does not support that the enrollee 
has tried and failed Euflexxa, Supartz FX, Durolane, or Gelsyn-3. The documentation does not support that 
Euflexxa, Supartz FX, Durolane, or Gelsyn-3 would likely be less effective and/or likely have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on January 04, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that the service 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 diabetic supplies 
provided on January 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravascular lithotripsy (C9764, C9765, C9766, 
C9767). 
 
You asked the Plan to pre-approve intravascular lithotripsy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental/investigational and not medically necessary for the 
enrollee's condition. 
 
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 intravascular lithotripsy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation suggestive of limb threat. The enrollee has a history of 
back pain, lumbosacral disc disease, back surgery, arthritis, chronic pain syndrome, neuropathy, and severe 
obesity. His walking distance is a very short distance and he had leg pain severe enough to require an 
emergency room visit although his ankle-brachial index (ABI) turned out to be normal at 1.0 on the right and 
mild at 0.86 on the left. His severe symptoms are bilateral despite the normal ABI on the right.  All these 
factors strongly suggest alternative causes for his symptoms, and that the chance of the patient experiencing 
meaningful improvement in his walking distance or quality of life from lower extremity arterial intervention is 
low.  Perhaps most importantly, as he experienced minimal or no relief in his symptoms from his previous 
arterial intervention on the left, the initial plan to treat arteries on the right at that time were abandoned as it 
was surmised that the etiology of the enrollees symptoms was unlikely to be vasculogenic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravascular lithotripsy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intravascular lithotripsy (C9764, C9765, C9766, C9767).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit, and related services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visit, and related services. You say that you need these services 
due to your pain. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office visit, and related services to be provided by an out-of-network (OON) provider.