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

 
We decided that the Plan does not have to pay for radiofrequency ablation (64625) provided on February 21, 
2020. 
 
You asked the Plan to pay for radiofrequency ablation. You say that this is not experimental. The Plan denied 
your request. The Plan says this is experimental. 
 
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 pay for radiofrequency ablation. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical literature indicates that there is limited data supporting the 
safety and efficacy of this treatment. There is a lack of large volume, long-term peer-reviewed outcome studies 
to support the use of these procedures for this patient. In this case, there is also no clinical documentation 
relative to sacroiliac joint pain or positive provocative testing in the submitted documentation to support the 
medical necessity of the radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pay for radiofrequency ablation (64625) provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 30, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration because you 
are in network with Medicare and the Plan. The Plan denied your request. The Plan says utilization of network 
providers is required when possible and available. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 30, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and intravenous sedation provided on January 28, 
2020. 
 
You asked the Plan to pay for the crown and intravenous sedation. You say that you were not informed the 
dentist was a private contractor. You say that you paid with the understanding you would be reimbursed. The 
Plan denied your request. The Plan says payment cannot be issued for services performed by a provider who 
has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the crown and intravenous sedation provided on January 28, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for a Bupivacaine injection (J3490) provided on September 19, 2019. 
 
You asked the Plan to pay for a Bupivacaine injection. You say that this should be covered. The Plan denied 
your request. The Plan says that this drug is not separately payable. 
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Though the plan states that the drug at issue is not separately payable, the 
submitted documentation was insufficient to verify payment for this drug is included in another code. The drug 
at issue was billed with an unlisted code. No medical records or other documentation have been submitted by 
the Plan to substantiate their denial reasoning. Therefore, we decided that the Plan has to pay for a Bupivacaine 
injection (J3490) provided on September 19, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99327) rendered by the out of network 
(OON) provider on January 31, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the rest home visit (99327) rendered by the out of network (OON) provider on January 31, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is not shown to have predominantly axial pain, associated with 
radiculopathy or neurogenic claudication. 
 
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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have multiple probable pain generators, and therefore, do not meet the criteria of the LCD. 
You have multi-level forminal stenosis, degenerative disc changes and post surgical changes. 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional dental services. 
 
You asked the Plan to pre-approve additional dental services. You say that you were not able to keep your 
dental appointment last year. You say that insurance should pay the $1,500 that you would have been able to 
use last year. The Plan denied your request. The Plan says you have exhausted your dental 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, you also have an annual allowance of 
$800. The Plan paid $800 toward dental services received on January 8, 2020, which exhausted your benefit. 
Therefore, we decided that the Plan does not have to pre-approve additional dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ankle brace provided on March 6, 
2020. 
 
You asked the Plan to waive the coinsurance for an ankle brace. You say that the brace broke and the supplier 
could not replace it. The Plan denied your request. The Plan says the coinsurance you are being charged is 
correct. 
 
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 40% 
coinsurance for each out of network Medicare-covered item. 
 
The allowed amount for your ankle brace was $86.14, therefore you have been asked to pay a $34.46 
coinsurance for an ankle brace ($86.14 x 40% = $34.46). An ankle brace falls within the Durable Medical 
Equipment (DME) and related supplies 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 coinsurance 
for an ankle brace provided on March 6, 2020.  
 
Your complaint about the brace breaking is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 2, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on February 27, 2020.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient services provided on February 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on March 30, 2020. 
 
You asked the Plan to pay for the services provided. You say that this is a payable procedure code. The Plan 
denied your request. The Plan says there is no documentation for an interpretation for the rendering provider at 
issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. 
Without a complete, written report similar to that which would be prepared by a specialist in the field, does not 
meet the conditions for separate payment of the service. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrocardiogram provided on March 30, 2020.
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 (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Reclast (zoledronic acid). 
 
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 (J0897). Our reviewer says that 
the drug is not reasonable and medically necessary. Our physician reviewer found reviewed documentation 
does not support a history previous treatment, contraindication, or intolerance to zoledronic acid. Without the 
support of the documentation, Prolia is not approved as step criteria is not met. The denial 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 Prolia (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve the PMD. You say that you are not able to walk very far with your walker 
and your doctors will provide information about why you need this. The Plan denied your request. The Plan 
says neither of your providers was aware of the request for the PMD. There is no documentation to indicate 
that this was ordered by a treating physician. 
 
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.  
 
The file does not document that you have a mobility deficit which impairs your abilities to participate in 
MRADLs in the home or that this deficit could not be resolved by a cane, walker, or manual wheelchair. 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 (PMD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the prescriber has not stated why the step therapy drugs would not be as effective. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found step therapy, as outlined 
by the plan, requires a trial and failure or documented contraindication to Retacrit. The documentation does not 
support these criteria were met. Medical necessity cannot be determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Procrit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture. 
 
You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that you need 
dentures to eat. The Plan denied your request. The Plan says the services are 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 
complete upper denture and lower partial denture.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tamsulosin HCL 0.4 mg Tablets. 
 
You asked the Plan to pre-approve Tamsulosin HCL. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Tamsulosin HCL 0.4 mg 
Tablets.  
 
Benefits for Tamsulosin HCL 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the MRI, orbit, face, and/or neck; without contrast material(s), 
followed by contrast material(s) and further sequences (CPT Code 70543). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says that the MRI is not 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 the MRI. Our physician reviewer found 
the study is indicated given palsy. The patient may have inflammation or mass. Therefore, the study is 
reasonable and indicated. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
the MRI, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further 
sequences (CPT Code 70543).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Praluent Pen prescription. 
 
You asked the Plan to pre-approve a Praluent Pen prescription. You say that this is medically necessary. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
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 a Praluent Pen prescription.  
 
Benefits for a Praluent Pen prescription may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.