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

 
We decided that the Plan does not have to pre-approve platelet rich plasma 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 there are currently 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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at the present time the body of literature on the use of PRP in this condition is largely limited to 
case reports and a report from an undersized pilot study.  There have not been any well designed clinical 
studies undertaken of this treatment approach to date. In as much the proposed service would be best classified 
as being experimental/investigational in nature. There is not sufficient literature to permit a conclusion that 
PRP is safe or effective for the member's condition. Nor does the use of PRP reflect the generally accepted 
standards of practice or care. For these reasons, the proposed services would not meet Medicare criteria for 
coverage. 
 
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 platelet rich plasma injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has deluxe features that exceed medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term 
outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity 
paralysis/paresis from conditions such as the enrollee's hemiparesis post tumor resection. The MyoPro Orthosis 
is not the most appropriate available supply or level of service for the patient in question considering potential 
benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific 
evidence and not the standard of care for this enrollee's hemiparetic condition. There is insufficient evidence in 
the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve 
hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
therapy rendered on September 4, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that TENS for chronic low back pain (CLBP) is covered 
when the beneficiary is enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was not in a Medicare-approved 
clinical study for these services. 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 pay for the 
transcutaneous electrical nerve stimulation (TENS) therapy rendered on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sanexas electrical stimulation treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary, as you are in 
extreme pain. The Plan denied your request. The Plan says you have not previously tried a less intensive 
treatment. 
 
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 treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the overall utility of Electroanalgesia for the management of pain due to DPN has yet to be 
demonstrated in any well designed clinical studies. Rather the limited evidence on this technology can only be 
found on the manufacturer's website. The use of this specific therapy/device/treatment does not otherwise 
reflect the generally accepted standards of practice/care. Rather the requested technology would be more 
appropriately classified as being experimental or investigational in nature. Therefore this service would not be 
eligible for coverage 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 the treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sanexas electrical stimulation treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete lower denture (D5120) 
 
You asked the Plan to pre-approve the complete lower denture. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the medical 
necessity of the service requested. 
 
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 complete 
lower 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 complete lower denture. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the provided X-rays 
show a pre-treatment condition where there are at least one viable molar and one viable premolar on each sides 
of the dental arch, suitable for clasping for a partial denture. From the provided X-rays it cannot be ascertained 
there was necessity to remove all the remaining lower teeth such that a full denture would be required. The 
logical treatment would be to retain two teeth at a minimum on each side of the arch and fabricate a partial 
denture. A full denture would not be the logical treatment choice and cannot be considered medically 
necessary. 
 
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 complete lower denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for lab work. You say that you do not think that you should have a 
copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $20 
copayment for outpatient diagnostic tests/lab services/freestanding laboratory.  
 
You have been asked to pay a $20 copayment for lab work. The correct copayment has been applied to the lab 
work that was provided. Lab work falls within the outpatient diagnostic tests/lab services/freestanding 
laboratory benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a 
participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical record must show a reasonable expectation that criteria will be met by the 
time of admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
living at home after being treated for a stroke with residual hemiparesis. He has been receiving home physical 
therapy services. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided 
on August 25, 2020. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that you would like reconsideration because 
this provider rendered the technical component and submitted the claim prior to the physician. The Plan denied 
your request. The Plan says a primary code has not been found in the member's claim history. 
 
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, we have confirmed that code the 
fluoroscopic guidance is an add-on code and cannot be paid as billed as it was not billed with a required 
primary code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided on 
August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve an oral appliance form an out of network provider. You say that the in-
network dentists are not suppliers. The Plan denied your request. The Plan says they will approve the oral 
appliance from an in network provider. 
 
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 
an oral appliance to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair and an upright walker. 
 
You asked the Plan to pre-approve the items. You say that it is unsafe for you to be standing in the shower. The 
Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that shower chairs are not covered because they are not primarily 
medical in nature. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that there any medical necessity for an upright walker. The upright walker is 
not a covered device by Medicare. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a bath/shower chair and an upright walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Ophthalmological services, medical examination and 
evaluation with initiation of diagnostic and treatment program (92004) provided September 29, 2020. 
 
You asked the Plan to pay for the vision services. You say that you have vision insurance with the plan but the 
vision claim section advised that this claim be sent to medical. You would like to know why this claim has not 
been paid. The Plan denied your request. The Plan says this claim was processed and the correct cost share was 
applied per the Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 out of network deductible.  
 
The item or service you asked the Plan to pay for falls within the benefit category Vision care. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $500 out of network deductible. The 
records show that you only met $154.68 of the 2020 deductible. Once the deductible has been met you are 
responsible for a 50% coinsurance for out of network vision services. This cost sharing is a contractual 
obligation that had not been met at the time the vision services was received on September 29, 2020. Therefore, 
we decided that the Plan does not have to pay for Ophthalmological services, medical examination and 
evaluation with initiation of diagnostic and treatment program (92004) provided September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 18, 2020. 
 
You asked the Plan to pay for the services. 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 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 periapical x-rays (D0230) provided on September 10, 
2020. 
 
You asked the Plan to pay for the dental services. You say that the dentist was trying to determine if you have 
temporal aortitis. You say that due to the x-rays that you received, the dentist was able to determine that the 
pain you were experiencing in your jaw area was not a result of a dental problem. You also say that this service 
should be covered as it was necessary to determine your diagnosis. The Plan denied your request. The Plan 
says periapical x-rays are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 
periapical x-rays (D0230) provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of lead wires provided on September 22, 
2020. 
 
You asked the Plan to pay for the lead wires. You say that code A4557 is separately reimbursable. The Plan 
denied your request. The Plan says a TENS unit has been purchased in the previous 12 months. 
 
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 A4557 is lead wires, (e.g., apnea monitor), per pair. We 
find that CPT code A4557 is not supported in the medical record. Specifically, the records show that lead wires 
were provided within the last 12 months. There are insufficient records to show that addition lead wires is 
medically reasonable and necessary for the enrollee's device. 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 pay for 
the replacement of lead wires provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 27 2020. 
 
You asked the Plan to pay for the services provided. You say that you went to an urgent care center. The Plan 
denied your request. The Plan says services were available in-network. 
 
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. The medical records provided show that you were seen for a follow-
up visit. The services were not urgent or emergent. The need for services was known prior to care being 
provided. 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 pay for the medical services provided on July 27 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is
receiving appropriate care in the inpatient rehab facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that the enrollee is at a moderate to maximal assist level for transfers, maximal assist for bathing,
minimal assist for upper body dressing, and total assist for lower body dressing, minimal assist for bed
mobility, and total assist for toileting. The progress note states her lungs are clear, and she is medically stable.
The enrollee does not have complex wound care, enteral feedings or other ongoing SNF level skilled nursing
needs. Her functional level does not require a qualified therapist to provide medically necessary and reasonable
treatment in a SNF. She does not require skilled nursing or skilled therapy services on a daily basis in a SNF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.