Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for nursing, physical therapy, and 
home health aide. 
 
You asked the Plan to pre-approve home health services for nursing, physical therapy, and home health aide. 
You say that the requested home health services for nursing, physical therapy, and home health aide are 
medically necessary. The Plan denied your request. The Plan says the requested home health services for 
nursing, physical therapy, and home health aide are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 home health services for nursing, 
physical therapy, and home health aide. Our reviewer says that the requested home health services for nursing, 
physical therapy, and home health aide are not medically necessary. Our physician reviewer found the records 
do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the 
enrollee's condition and/or prevent deterioration. There are no complex wounds, new enteral feedings or other 
skilled nursing need. The records do not show that skilled therapy is needed to effectively provide treatment, 
care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee's gait is smooth 
and normal, there is no focal weakness. The enrollee's functional deficits do not require skilled therapy in the 
home. There is no evidence that leaving the home is a taxing effort and that the enrollee is truly home bound.  
As the enrollee does not require skilled therapy or skilled nursing services and the enrollee is not home bound 
the enrollee does not meet the definition of home health aide services and the request for home health aide 
services are not 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 home health services for nursing, physical therapy, and home health aide have 
not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for 
nursing, physical therapy, and home health aide.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinous spacer. 
 
You asked the Plan to pre-approve spinous spacer. 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 spinous spacer. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic back pain. The requested device is 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 spinous spacer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinous spacer.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the head. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a clinical diagnosis of 
Bell's Palsy with facial weakness. The provider has concerns for vascular pathology, and while MRI may be a 
better study for Bell's Palsy alone, the need for information about the vascular system makes the requested CT 
with contrast a better study. The CT scan is reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the head.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #5. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the documentation 
does not demonstrate the need for replacement of the existing crown. 
 
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 crown 
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 crown. Our reviewer says that the 
crown is not medically necessary. Our physician reviewer found the documentation provided does not indicate 
that the criteria for a replacement crown for tooth #5 have been met. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) 
nerves. 
 
You asked the Plan to pre-approve the knee RFA procedure. You say that you have severe pain which is 
causing you to fall and you feel that this treatment would be helpful. The Plan denied your request. The Plan 
says current clinical evidence does not support that medical necessity of this type of treatment for your 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the knee RFA procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of left knee osteoarthritis documented on MRI and physical 
exam. The patient had diagnostic genicular nerve blocks that provided greater than 80% pain relief. The 
provider has requested genicular radiofrequency ablation to treat this knee pain. This is an experimental/ 
investigational procedure that is being studied in ongoing clinical trials. She is not enrolled in a clinical 
trial. 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 knee RFA procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that this would be helpful for you to get control of your 
diabetes. The Plan denied your request. The Plan says you do not meet the Medicare criteria for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered when the above criteria are 
met. 
 
In this case, the records shows that you only use two insulin injections per day and that the doses of these 
injections are not adjusted based on blood sugar readings. As such, the rules for coverage of the CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrolee has a history of sacroilitis, 
chronic pain syndrome, and lumbar radiculopathy. He has had two successful SI joint injections in the past 10 
months. The requested RFA of the SI joint is considered experimental in nature and is therefore not reasonable 
or medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you have used this eye doctor in the past 
and you like the level of customer service you receive there. The Plan denied your request. The Plan says you 
must use providers in your network. The Plan says that you have been provided authorization with a network 
eye specialist. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the JAK2 Exon 12 genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that JAK2 Exon 12 testing described by procedure code 
81270 is limited to specific diagnoses only. 
 
We looked at the file and Medicare rules. The JAK2 Exon 12 testing is being requested for a diagnosis of 
D69.6 (unspecified thrombocytopenia). This is not a diagnosis for which Medicare covers this testing. 
Therefore, we decided that the Plan does not have to pre-approve the JAK2 Exon 12 genetic testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT 
of the abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have a diagnosis of colon cancer. There are no submitted medical records documenting a need for the requested 
CT scans. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest and CT of the abdomen/pelvis.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a new Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the new PWC. You say that the enrollee requires a new PWC as the current 
chair is over 8 years old. The Plan denied your request. The Plan says that there is no evidence that the current 
chair cannot be repaired. Therefore, replacement is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if an enrollee has used a piece of equipment for 
its reasonable useful lifetime, then he/she may elect to obtain a new piece of equipment.  
 
In this case, the documentation shows that the current chair has been in use for 8 years, which is longer than the 
reasonable useful lifetime. As such, Medicare rules allow the enrollee to elect a new piece of equipment. 
Therefore, we decided that the Plan has to pre-approve a new Group 3 power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2740) for tooth #'s 22 to 25. 
 
You asked the Plan to pre-approve the crowns (D2740) for tooth #'s 22 to 25. You say that you went to the 
dentist to start your crown. You say that you were told it was all taken care of. The Plan denied your request. 
The Plan says your benefit has been exhausted for the 2020 plan year. 
 
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 a maximum benefit of 
two crowns per calendar year. The Plan pre-approved two crowns on May 23, 2020, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2740) for tooth #'s 22 
to 25.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment; subsequent motor threshold re-determination with delivery and management (CPT Codes: 
90869, 90867, 90868). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the information provided, this patient does not meet the clinical criteria for the use of 
TMS therapy utilizing LCD (L37088), as this patients PHQ 9 improved from 20 on April 9, 2020 to 4 on July 
1, 2020.  Utilizing the information from this enrollee that indicates this patient does not have an indication for 
the requested Repetitive Transcranial Magnetic Stimulation (rTMS) as he had shown a response previously 
with Repetitive Transcranial Magnetic Stimulation (rTMS) as his PHQ diminished as noted above. This patient 
does not meet the Medicare coverage criteria based on LCD (L37088) for retrial of Repetitive Transcranial 
Magnetic Stimulation (rTMS) and therefore is not considered medically necessary for this patient who suffers 
from Major Depressive Disorder. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent 
motor threshold re-determination with delivery and management (CPT Codes: 90869, 90867, 90868).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an 
out of network provider. 
 
You asked the Plan to pre-approve physical and occupational therapy. You say that there is no in-network 
provider that can provide the same level of service. You say that on sight services should be utilized for the 
safety of the enrollee and community. The Plan denied your request. The Plan says services are available in-
network. The Plan also says therapy was approved for an in-network provider through home health services. 
 
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 and occupational therapy to be provided by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee had a recent 
fall and has a new need for physical therapy. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 10 additional 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 goals include reducing pain, 
restoring function and education regarding a home exercise program. Our reviewer says that there is no 
indication residual deficits could not be addressed through a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493). 
 
You asked the Plan to pre-approve the services. You say that your pain radiates down the right leg, you cannot 
walk too far and you are not a candidate for surgery. The Plan denied your request. The Plan says the Medicare 
rules have 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not meet medical criteria or medical necessity for lumbar/sacral facet joint block. Per 
the documentation, you have a history of chronic back pain and previously had a lumbar facet injection with 
60% relief for eight weeks. Guidelines recommend repeat therapeutic injections when there is greater than 50% 
relief for at least three months. Given that you did not have more than three months of relief the request is not 
medically necessary. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage for injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
Code 64493).