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

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the incisional biopsy 
of oral tissue (D7286) provided on October 6, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied 
your request. The Plan says that you have exceed your frequency limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers one limited 
exam to evaluate a problem (D0140) per year.  
 
We looked at the file and Medicare rules. The file indicates the Plan has already covered a limited oral 
evaluation on September 16, 2020. The incisional biopsy of oral tissue is not among the covered services under 
this benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and 
the incisional biopsy of oral tissue (D7286) provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 above.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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-approveacute IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays received on July 22, 2020. 
 
You asked the Plan to pay for the services. You say that payment should be reconsidered. The Plan denied your 
request. The Plan says they do not offer benefits for periapical x-rays. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periapical 
x-rays received on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmology services provided on 
August 7, 2020. 
 
You asked the Plan to waive the copayment for ophthalmology services. You say that you disagree with the 
charges because this was a normal eye exam. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $45 
copayment for each specialist visit.  
 
You have been asked to pay a $45 copayment for ophthalmology services. Ophthalmology services fall within 
the physician/practitioner services, including doctor?s office visits 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 ophthalmology services provided on August 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has 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 inpatient mental health treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of February 14, 2021 forward as you 
were not shown to be a danger to yourself or others. You were not showing any auditory or visual 
hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety of 
yourself or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health treatment.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 based on the documentation provided, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs 
can be met at 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from 
February 5, 2021, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required 
skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing 
needs. As of February 5, 2021, the enrollee did not require any skilled nursing or rehab services on a daily 
basis. The enrollee was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require 
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care as of February 5, 2021. The enrollee 
did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee 
received skilled care and improved; however, their function had plateaued by February 4, 2021, and the 
enrollee did not require any further inpatient skilled rehab services. The enrollee's function was at or near their 
prior level of function and they could be discharged to a lower level of care for further services. As of February 
5, 2021, the member required custodial services. The denial for further inpatient skilled care is upheld.   
 
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 continuation of SNF care provided to the enrollee from February 5, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that your dentist does not want you to take any 
bisphosphonates. The Plan denied your request. The Plan says you have not first tried and had a 
contraindication or intolerance to a bisphosphonate such as Reclast or Fosamax or a combination or oral and IV 
bisphosphonates. 
 
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 Prolia. Our reviewer says that the drug 
is not reasonable or medically necessary. Our physician reviewer found based on the medical records provided 
the patient has not tried and failed the required drugs. Based on the medical records provided there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
patient. Prolia carries a precaution with regard to osteonecrosis of the jaw as do bisphosphonates. Based on the 
medical records provided the patient does not have a history of an osteoporosis related fracture. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(0275T) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that Medicare will only allow this procedure when you are enrolled in 
an approved clinical trial or study. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression is covered if you are enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. The file does not indicate the enrollee is enrolled in a clinical study. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar 
decompression (0275T) for the enrollee.
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 there is still lower limb weakness. The Plan denied 
your request. The Plan says an inpatient stay cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lower extremity weakness and an episode of urinary incontinence. Imaging revealed no anatomic cause for the 
symptoms, which are improving. Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet 
joint nerve(s); lumbar or sacral, each additional facet joint (64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or 
sacral, single facet joint and destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or sacral, 
each additional facet joint. You say that the services are necessary. The Plan denied your request. The Plan says 
based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RF ablation at the same 
anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 50% 
improvement in pain for at least six (6) months. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s); lumbar or sacral, single facet joint and destruction by neurolytic agent, 
paravertebral facet joint nerve(s); lumbar or sacral, each additional facet joint. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of the degree 
and duration of the pain relief following the radiofrequency ablation (RFA) performed in January 2020. The 
electromyography (EMG) shows right polyradicuopathy and there is a lack of physical exam documentation of 
the facet joints, facet loading tests and limitations of range of motion. Therefore, the requested procedure is 
deemed not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or 
sacral, single facet joint and destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or sacral, 
each additional facet joint have not been met. Therefore, we decided that the Plan does not have to pre-approve 
destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or sacral, single facet joint (64635) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s); lumbar or sacral, each additional facet 
joint (64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic.
You asked the Plan to pre-approve Ozempic. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myocycle device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for multiple sclerosis. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the evidence for the effectiveness of the Myocycle device in people with multiple sclerosis is limited. 
There is insufficient evidence in the literature that supports that the use of the Myocycle will be effective for 
your condition or in individuals with quadriplegia or paraplegia in long term improvement of muscle strength, 
vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor 
movement or reduction muscle atrophy in the upper and lower extremities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myocycle device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of orbit, face and/or neck (70543). 
 
You asked the Plan to pre-approve an MRI of orbit, face and/or neck (70543). You say that the requested MRI 
of orbit, face and/or neck (70543) is medically necessary. The Plan denied your request. The Plan says the 
requested MRI of orbit, face and/or neck (70543) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of orbit, face and/or neck 
(70543). Our reviewer says that the requested MRI of orbit, face and/or neck (70543) is not medically 
necessary. Our physician reviewer found this enrollee cited right sided neck pain. A history of cervical fusion is 
documented. The pain is worse when he turns to the right and the pain is on the left trapezius area. There is 
some pain in the second, third fingers of his left hand. Exam reveals tenderness to palpation of the left trapezius 
area and he has pretty good range of motion throughout. There is some swelling in the anterior left, right side 
of his neck. 
 
However, documentation does not support recent x-rays having been performed. Furthermore, documentation 
of severe and/or progressive neurological deficits has not been provided. Evaluation post Tizanidine and 
Voltaren being prescribed (on 1/4/21) has not been documented. Therefore, the requested MRI of orbit, face 
and/or neck (70543) is not medically reasonable and necessary for the enrollee in this case. 
 
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 MRI of orbit, face and/or neck (70543) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of orbit, face and/or neck (70543).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device. 
You asked the Plan to pre-approve the device. You say that this is needed to treat the enrollee's lumbar stenosis. 
The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer remains experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvearthrocentesis of temporomandibular joint (TMJ) (20605).You asked the Plan to pre-approvearthrocentesis of TMJ. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvearthrocentesis of temporomandibular joint (TMJ) (20605).