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

 
We decided that the Plan has to pre-approve lumbar radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the above criteria 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 pre-approve the RFA. Our reviewer says that the 
requested RFA is medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that the enrollee has had 2 sets of diagnostic medial branch blocks with greater than 80% pain relief. The 
requested procedure is medically reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve 
lumbar radiofrequency ablation (RFA).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear stress test. 
 
You asked the Plan to pre-approve a nuclear stress test. You say that this is necessary for the enrollee to obtain 
his pilot's license. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that tests performed when the results would not be 
anticipated to influence medical management decisions will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The records show that a stress test was requested to fulfill a 
requirement for the enrollee's pilot license rather than to inform his medical treatment. This is considered not 
medically necessary and is therefore not covered under Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of a nuclear stress test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nuclear stress test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint RFA.
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the documentation provided for review does not support that the median branch of the nerve innervating the paravertebral facet joint is the target for the destruction.
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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not support that the requirements for Medicare's Local Coverage Determination have been satisfied. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint RFA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement transmitter for a Guardian continuous 
glucose monitoring (CGM) system coded as A9277 and A9276. 
 
You asked the Plan to pre-approve the replacement transmitter. You say that your transmitter died 2 weeks ago 
which means you can?t use the sensor that was approved. You need this equipment to keep your sugars under 
control. The Plan denied your request. The Plan says this device is considered a non-therapeutic CGM and is 
not a Medicare covered device, therefore, the replacement transmitter is also non- covered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the replacement transmitter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a replacement transmitter for a Guardian continuous glucose monitoring (CGM) system coded 
as A9277 and A9276.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by out of network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have seen this therapist since 2015. You 
say that you don't want to start all over with someone else. The Plan denied your request. The Plan says 
services are available 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 to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you would like your dentures to 
be approved because you need it as soon as possible. The Plan denied your request. The Plan says the service is 
not medically necessary. 
 
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 the 
mandibular partial denture when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the mandibular partial denture. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there will be at least six 
natural teeth in the lower arch in contact with the upper denture, making for twelve teeth being in occlusion.  
Our reviewer also found that given the limitations of the Plan, there is no medical necessity for the requested 
partial denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the mandibular partial denture have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for removal of pacing cardioverter-
defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator. 
 
You asked the Plan to pre-approve the physician's services. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the services are available 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 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 
physician's services for removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing 
cardioverter-defibrillator pulse generator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a spinal spacer device. 
 
You asked the Plan to pre-approve the spacer device. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says there are no clinical indications for 
this technology. 
 
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 spacer device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is experimental and more research is needed to show its 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 spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the insertion of a spinal spacer device.
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 you need a fully electric bed with 
half rails instead of full rails. You have been unable to get in and out of bed without assistance and have been 
confined to a reclining chair. The Plan denied your request. The Plan says a total electric hospital bed is not 
covered by Medicare or the Plan. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that you cannot move without a scooter. 
The Plan denied your request. The Plan says criteria for a power mobility device have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
Your assessment shows that you do not have a mobility deficit that impairs your participation in MRADLs and 
your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. 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 spinal surgery. 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 spinal stenosis. The documentation does not include recent imaging studies 
showing severe stenosis or spinal instability. Criteria for lumbar spine decompression and fusion surgery not 
met. There is no correlation between and physical exam findings and imaging. 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vasectomy. 
 
You asked the Plan to pay for vasectomy. 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 a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
vasectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210) of tooth #'s 4, 5, 10, 11, and 12. 
 
You asked the Plan to pre-approve the extractions of tooth #'s 4, 5, 10, 11, and 12. You say that the surgical 
extractions are necessary. The Plan denied your request. The Plan says the extractions benefit for tooth #'s 4, 5, 
10, 11, and 12 has been exhausted. 
 
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, extractions (D7210) are limited to once 
per tooth. The record shows that the enrollee received extractions (D7210) of tooth #'s 4, 5, 10, 11, and 12 on 
June 18, 2020 and the enrollee's extractions benefit for these teeth have been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve extractions (D7210) of tooth #'s 4, 5, 10, 11, and 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve the drugs or medicaments. The Plan denied your request. The Plan says this 
service is not covered by the enrollee's 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, 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 
drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic. 
 
You asked the Plan to pre-approve the pontic. You say that you are on antibiotics due to an infection. You say 
that this is the only option to prevent that. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve 12 physical therapy visits. You say that the necessary therapy can only be 
provided by a skilled therapist. The Plan denied your request. The Plan says the enrollee has already had the 
amount of therapy allowed under the Plan and further therapy will not be covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are not 
required to safely and effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral decompression therapy. 
 
You asked the Plan to pre-approve vertebral decompression therapy. 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 a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that vertebral decompression therapy is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of vertebral decompression therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebral decompression therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve functional electrical stimulation (FES) device (E0770) 
with an out-of-network provider with in-network benefits. 
 
You asked the Plan to pre-approve FES device. You say that you strongly disagree with the conclusion by the 
Plan and respectfully request reconsideration of this determination. The Plan denied your request. The Plan 
says the records does not support that the enrollee meets the Medicare criteria for FES. 
 
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 FES device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the enrollee is noted to have suffered a stroke and has residual left hemiplegia. He 
has no history of a spinal cord injury, nor are his deficits with ambulation associated with a SCI. In as much the 
criteria for coverage of a FES device have not been met 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 FES device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve functional electrical stimulation (FES) device (E0770) with an out-of-network provider 
with in-network benefits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nervous system surgery. 
 
You asked the Plan to pre-approve nervous system surgery. 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 nervous system 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 chronic low back pain, lumbar radiculopathy and lumbosacral 
radiculopathy. The radiculopathic nature of the pain is documented in the office notes as a burning pain 
radiating through the buttocks and bilateral lower extremities to her feet, associated with numbness and 
paresthesia. You report reduction of pain following a left L4, S1 Transforaminal epidural steroid injection on 
April 28, 2020. The pain relief lasted a day and a half, and then abruptly returned to baseline pain. You have 
been receiving physical therapy or home exercises, is tolerant to nonsteroidal anti-inflammatory drugs, and is 
taking Voltaren gel, Gabapentin, cyclobenzaprine, Pennsaid and Percocet. The documentation does not support 
that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of nervous 
system surgery. Radiofrequency ablation is not considered the standard of care for the treatment of your 
condition. Therefore, you do 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 nervous system surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nervous system surgery.