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

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. The Plan denied your request. The Plan says this is 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 genicular RFA. Our reviewer says that 
the requested genicular RFA is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is considered an experimental/investigational technique, which is the subject of several 
on-going clinical trials. Its role in the treatment of osteoathritis is still being investigated.  Therefore, the 
request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant control for a power wheelchair for the 
enrollee. 
 
You asked the Plan to pre-approve the attendant control. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can operate the wheelchair, so the attendant control cannot be 
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 attendant control. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is not clear from the documentation that the enrollee is unable to operate a power wheelchair, 
and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. 
 
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 attendant control have not been met. Therefore, we decided that the Plan 
does not have to pre-approve attendant control for a power wheelchair for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept provided on April 4, 2019.  
 
You asked the Plan to pay for paramedic intercept services. You say that the Plan should bay this bill. The Plan 
denied your request. The Plan says Medicare does not regulate the compensation between the BLS entity and 
the ALS entity. If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the 
service, then only the BLS level of payment may be made. In this situation, the ALS entity's services are not 
covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are 
beyond the scope of the BLS level of payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the 
provider does not have a contract with the volunteer ambulance company that provided the transport services. 
Therefore, we decided that the Plan does not have to pay for paramedic intercept provided on April 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment charged for ambulance transport 
provided on July 20, 2020. 
 
You asked the Plan to waive this copayment. You say that you thought this would be covered by your 
insurance. The Plan denied your request. The Plan says this claim has been paid to the provider minus your 
$100 contractual copayment. 
 
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 $100 
copayment for ambulance transport.  
 
You have been asked to pay $100 copayment for this copayment. this copayment falls within the ambulance 
transport 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 $100 copayment charged for ambulance 
transport provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64494, 64493) to be provided 
by an out of network provider. 
 
You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says the requested provider is not a network provider. There 
are network providers available that can provide the services at issue. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the facet 
joint injections (64494, 64493) to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The Vertiflex Superion interspinous spacer device. 
 
You asked the Plan to pre-approve The Vertiflex Superion interspinous spacer device. You say that you would 
like the plan to reconsider their 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 The Vertiflex Superion interspinous 
spacer device. 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 low back pain. The requested spacer is 
considered experimental. More research is needed to show safety and efficacy. 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 The Vertiflex Superion interspinous spacer device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve The Vertiflex Superion interspinous spacer 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services (89841, 98940, 99203, 99213) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the provider at issue is not a network provider. The services are 
not emergent. Additionally, Chiropractic services other than spinal manipulation are non-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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
chiropractic services (89841, 98940, 99203, 99213) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on  
May 19, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $390 
copayment per day, for days 1 to 5, for inpatient hospital care.  
 
You have been asked to pay $390 ($390 copayment x 1 day) for the in-network inpatient hospital care 
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
The record shows that you were admitted to the hospital as inpatient at 2:30 pm on May 19, 2020 and received 
an examination by a hospital physician. You were discharged from the hospital per your request at 5:38 pm, 
despite medical advisement. Although you did not stay overnight in the hospital, you are responsible for the 
inpatient copayment applied. Inpatient hospital care starts the day you are formally admitted to the hospital 
with a doctor's order. 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 inpatient hospital care 
provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecardiology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON cardiology services. You say that you were injured in a bus accident and your lawsuit was blocked. You say that you will not let the Plan tell you who you can and cannot go to for your care. You say that the Plan may have been paid off by the bus company who blocked your lawsuit.The Plan denied your request. The Plan says it is not medically necessary for the enrollee to go to an out of network provider. The Plan says that a network gap does not exist.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-approvecardiology services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750). 
 
You asked the Plan to pre-approve the pontic (D6240) and retainer crown (D6750). You say that you have no 
biting surface on both sides of your mouth and are in pain. You say that the implants failed and had to be 
removed. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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-approve the 
pontic (D6240) and retainer crown (D6750).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says the documentation 
does not show that the enrollee meets the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Procrit. Our reviewer says that the 
service is not reasonable or medically necessary. Our physician reviewer found in order for Retacrit to work 
adequate iron stores are needed. Our reviewer found that this enrollee has evidence of iron deficiency anemia 
with an iron saturation of 10% and a ferritin of 10. Our reviewer also found that iron would need to be repleted, 
and the hemoglobin reassessed as Epogen may not be needed 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress. 
 
You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that your bed is broken 
and too old to get repaired. The Plan denied your request. The Plan says the medical records received did not 
indicate that you have present ulcers. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show you have ulcers at this time or have had 
flap surgery within the past 60 days. Based on this information, we decided that Medicare rules for coverage of 
a powered pressure reducing air mattress have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered pressure reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
requested feature does not meet a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the lower extremity (73721).You asked the Plan to pre-approvethe MRI. You say that the MRI is medicallynecessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found in this case there is no specific clinical rationale for the requested MRI of the lower extremity. The review has determined that the requested MRI is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the lower extremity (73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of knee cartilage using an endoscope. 
 
You asked the Plan to pre-approve knee surgery. You say that your doctor told you that this surgery would fix 
your issue. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the documentation does not show that you have failed all conservative measures. 
 
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 knee surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a 7-month history of right medial knee pain with no history of trauma. Clinical 
examination findings have documented medial joint line tenderness and medial pain with circumduction 
maneuvers. There is radiographic evidence of mild medial and patellofemoral joint space narrowing. There is 
imaging evidence of focal Hoffa's fat pad edema anterior to the anterior horn of the medial meniscus. The 
requesting physician has reported imaging findings of a tear of the posterior horn medial meniscus. You have 
reportedly failed reasonable and/or comprehensive conservative treatment. A study concluded that positive 
McMurray sign implies good postoperative outcomes for patients with meniscal tear associated with 
osteoarthritis. For patients with osteoarthritis, those whose positive McMurray signs are in line with their 
radiological findings indicate they are eligible candidates for arthroscopic meniscectomy. In this case, there is 
no clear evidence of mechanical symptoms or positive McMurray's test to support the diagnosis of a medial 
meniscus tear. There is a discrepancy in the reading of the Magnetic Resonance Imaging (MRI) test between 
your treating physician and the radiologist. Therefore, the request for right knee arthroscopy with partial medial 
meniscectomy is not medically reasonable and 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 knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of knee cartilage using an endoscope.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab services to be provided by an out-of-area provider. 
 
You asked the Plan to pre-approve the lab services. You say that you need blood work so the doctor can advise 
you of any changes that may be needed. The Plan denied your request. The Plan says the request is not urgent, 
emergent, or unforeseen. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Covered services provided by non-plan providers are limited to 
unforeseen, urgently needed services when you are temporarily outside the service area. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lab services to be provided by an out-of-area provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for rib fractures and lung 
contusion after a fall. Your medical problems are stable. 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 does document 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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.