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

 
We decided that the Plan does not have to pre-approve a referral for a consultation with an out-of-network 
orthopedic surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this provider is out-of-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 
a referral for a consultation with an out-of-network orthopedic surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper and lower denture. 
 
You asked the Plan to pre-approve the dentures. You say that you are unable to eat and losing weight. The Plan 
denied your request. The Plan says the benefit 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. The Plan covers dentures once 
every five years. 
 
Dentures were last received on January 19, 2018, which is less than five years ago. Based on this information, 
we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper and lower denture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT, lower extremity; without contrast material, 
followed by contrast material(s) and further sections. 
 
You asked the Plan to pre-approve a CT (73702). You say that the enrollee has leg pain and needs a CT lower 
extremity. The Plan denied your request. The Plan says a CT lower extremity is 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 a CT (73702). Our reviewer says that a 
CT lower extremity is not medically necessary. Our physician reviewer found the location in the right lower 
extremity is not specified. If the mass is soft tissue ultrasound and plain films are often sufficient for 
evaluation. If the mass appears to be boney plain films are the first procedure of choice. Absent any details 
concerning the site of the mass, its palpable nature, and lack of at least plain films, medical necessity for CT of 
the lower extremity is not established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT (73702) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT, lower extremity; without contrast material, followed by contrast material(s) and 
further sections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left L4-5 foraminotomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no failure of conservative care. 
 
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 surgery. 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 of a recent trial and failure of PT. Surgery not needed at this time. More 
conservative measures including PT are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left L4-5 foraminotomy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the clinicals provided does not 
meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CMS specifies that PET/CT of the brain is covered ONLY if there is a differential diagnosis of 
Alzheimer disease versus Frontal Temporal Dysplasia and quantified cognitive decline increasing in the past 6 
months.  Repeat cognitive testing is planned but has not been done.  Also, the differential of AD vs FTD is 
never mentioned in the submitted records thus not qualifying this patient for PET imaging. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard colorectal cancer screening testing. 
 
You asked the Plan to pre-approve Cologuard. You say that you are at risk but do not want to have a 
colonoscopy at your age. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because you do not meet the Medicare criteria for Cologuard screening. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard screening testing is only covered for 
beneficiaries that meet the above criteria.  
 
We looked at the file and Medicare rules. You are not within the age range of 50 to 85 years. Based on this 
information, we decided that Medicare rules for coverage of Cologuard have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Cologuard colorectal cancer screening testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face-down positioning table. 
 
You asked the Plan to pre-approve a face-down positioning table. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a face-down positioning table.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services for a consultation for 
eye surgery. 
 
You asked the Plan to pre-approve the physician's services for a consultation for eye surgery. The Plan denied 
your request. The Plan says that the Plan may pay for you to be treated by a non-contracted doctor if we did not 
have any eye doctors for eye surgery in our network. This is not the case and we have eye doctors for eye 
surgery in your area. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services for a consultation for eye surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block, coded as 64490 and 64491, for 
neck pain. 
 
You asked the Plan to pre-approve medial branch block. You say that you had physical therapy in the past for 
your shoulder and over 15 years ago for your back and neck pain and didn't feel it helped but you're willing to 
participate if its the only way to be approved. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for medial branch block as there were no notes submitted that the member has tried physical 
therapy. 
 
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 medial branch block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of recent physical therapy or other conservative therapy. 
Therefore, the criteria of the LCD are not met and 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 medial branch block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch block, coded as 64490 and 64491, for neck pain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 core 
buildup for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is needed due to a diagnosis of hemiplegia 
and hemiparesis. The Plan denied your request. The Plan says Medicare does not cover durable medical 
equipment (DME) in a skilled nursing facility (SNF) based on statutory definition of DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the services is being requested for use in a SNF. A SNF is not counted as a home, according 
to Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and 
accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-service the walk-in bathtub. 
 
You asked the Plan to pre-service the walk-in bathtub. You say that you need this tub because it is much safer 
for you.  You have fallen several times and there is no one at home to help you. Everytime you take a bath you 
have to contact the fire department for help. The Plan denied your request. The Plan says this item is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-service the walk-in bathtub.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is recommended for its superiority in reducing 
fracture risk with the fewest side effects. The Plan denied your request. The Plan says Prolia does not have a 
benefit over an approved biphosphonate. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided, there is no documentation that Prolia is medically necessary and superior to the health plan's 
preferred first line therapy (bisphosphonate therapy) for fracture reduction. 
 
 
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 Prolia for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial due to your 
spinal cord being exposed and needing a higher level of care. The Plan denied your request. The Plan says you 
can have services at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that this treatment should be allowed to treat her pain. The 
Plan denied your request. The Plan says ESIs cannot be approved in the absence of radicular symptoms. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs can be considered reasonable and necessary 
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 ESI. Our reviewer says that the 
documentation does not support the medical necessity of the requested ESI. Our physician reviewer found the 
progress notes do not adequately characterize the radiculopathy that is present. 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve these services. You say that you need to see a physiatrist to get your 
medication. The Plan denied your request. The Plan says the request exceeds the mileage benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers up to 48 one-way trips and each one-way trip must not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
one-way trip for a total of 251 miles. Based on this information, we decided that the Plan?s rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation miles.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Euflexxa. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of Euflexxa. Our physician reviewer found that 
based on the medical records provided the patient has not tried and failed the required drugs. There is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (CPT D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the clinical information submitted supports 
the need for core buildup. The Plan denied your request. The Plan says the service in dispute is noncovered. 
 
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 core 
buildup (CPT D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental porcelain crowns fused to base metal (CPT 
D6751) and a dental porcelain pontic fused to base metal (CPT D6241). 
 
You asked the Plan to pre-approve the dental crowns and pontic. You say that you are in pain and have a large 
hole in your tooth. The Plan denied your request. The Plan says the requested codes are not in the coverage 
guidelines and the services being requested are noncovered. 
 
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 
dental porcelain crowns fused to base metal (CPT D6751) and a dental porcelain pontic fused to base metal 
(CPT D6241).