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

We decided that the Plan does not have to pre-approve 5 of the requested 10 additional in-home physical 
therapy visits. 
 
You asked the Plan to pre-approve 5 of the requested 10 additional in-home physical therapy visits. You say 
that you need the additional care. The Plan denied your request. The Plan says that rules for Home Health 
services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 5 of the requested 10 additional in-
home physical therapy visits. Our reviewer says that the requested services are not medically necessary. Our 
physician reviewer found the requested additional therapy is not generally accepted as specific and effective 
therapy for your condition. You have had extensive therapy for this condition and it does not appear that your 
functional level needs the unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 of the requested 10 additional in-home physical therapy visits have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 5 of the requested 10 additional in-home 
physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 repeat RFA is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
and has had diagnostic facet joint and trigger point injections. He also had kyphoplasty at T9. He had RFA on 
June 26, 2020 but the pain returned before six months' time. The repeat RFA does not meet the criteria for 
coverage and is 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 repeat radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits (97164). 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that these visits are necessary 
because the enrollee is improving. The Plan denied your request. The Plan says additional visits are not 
medically necessity. 
 
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 the patient has had prior therapy for this 
condition. The patient has been educated in a home exercise program and the documentation does not support 
that the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 (97164).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal. 
 
You asked the Plan to pre-approve a root canal. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
root canal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine Prilocaine cream (J3490). 
 
You asked the Plan to pre-approve Lidocaine Prilocaine cream. You say that the medication is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment 
of ESRD are included in the ESRD PPS and are not separately paid as of January 1, 2011.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Lidocaine Prilocaine cream have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lidocaine Prilocaine cream (J3490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital or ambulatory surgical center call (D9240). 
 
You asked the Plan to pre-approve the dental service. You say that your doctor's medical records were ordered. 
The Plan denied your request. The Plan says hospital or ambulatory surgical center call is not listed as a 
covered service. The contract also says any services not listed are not covered. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve a hospital or ambulatory surgical 
center call (D9240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device and the related 
accessories. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee required the 
service after knee surgery to prevent blood clots. The Plan denied your request. The Plan says pneumatic 
compression devices are not covered by Medicare for the prevention of blood clots. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
and the related accessories.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ropinirole extended-release 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 enrollee's plan does not have a Medicare Part D benefit or separate pharmacy 
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 Ropinirole extended-release 
for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental occlusal guard (D9944). 
 
You asked the Plan to pre-approve a dental occlusal guard. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item 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 a 
dental occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vascular embolization or occlusion (37242) provided on 
February 14, 2020. 
 
You asked the Plan to pay for vascular embolization or occlusion. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
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 37242 is vascular embolization or occlusion, inclusive of 
all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary 
to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial 
malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 
 
We asked our coder 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 vascular embolization or occlusion. Our reviewer says that 
CPT code 37242 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
documentation does not support a therapeutic introduction of vessel-blocking substances into the circulation to 
occlude vessels. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular embolization or occlusion have not been met. Therefore, we decided 
that the Plan does not have to pay for vascular embolization or occlusion (37242) provided on February 14, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical 
records provided there is no documentation that you require the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of wheelchair armrests with shorter desk-
length armrests. 
 
You asked the Plan to pre-approve desk-length armrests. You say that the advantage of the desk-length arms is 
you can get closer to a desk or table, which would greatly benefit you. The Plan denied your request. The Plan 
says the denial of authorization for these items and the associated labor is correct, because these do not serve a 
primarily medical purpose. 
 
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 replacement of wheelchair armrests with shorter desk-length 
armrests.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted procedure, dentoalveolar structures (CPT Code 
41899), reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial (CPT Code 
21248) and graft, bone; mandible (includes obtaining graft) (CPT Code 21215). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. The services are not a covered benefit under the plan. Therefore, we 
decided that the Plan does not have to pre-approve unlisted procedure, dentoalveolar structures (CPT Code 
41899), reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial (CPT Code 
21248) and graft, bone; mandible (includes obtaining graft) (CPT Code 21215).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on May 9, 
2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the reasonableness 
of the provided equipment has not been established. 
 
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 the neuromuscular stimulator. 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 evidence of an actual hands on physical examination documenting 
objective neurologic function and a detailed neuromuscular exam indicating objective muscle atrophy, 
strength/range of motion and instability testing of the bilateral lower extremities. The objective goals for this 
device were indicated to aid in stabilization of the low back and decrease knee and back pain. The 
documentation is not clear how this device will stabilize the low back or affect knee and back pain. The 
requested item  does appeal to be the standard of care for this condition and exceeds the member's medical 
need. 
 
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 neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for the neuromuscular stimulator (E0745) provided on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reconstructive Orthopedics to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the services. You say that you would like to see this provider. The Plan 
denied your request. The Plan says there are in-network options available that can provide the 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 
Reconstructive Orthopedics to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acitretin. 
 
You asked the Plan to pre-approve Acitretin. The Plan denied your request. The Plan says this is not covered 
under the enrollee's Part B 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 Acitretin.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 a maximum of 20 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided on March 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment as you went to the emergency room for a COVID check-up. The Plan denied your request. 
The Plan says the copayment has been applied correctly to the service provided. 
 
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 $65 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $65 copayment for the Medicare-covered emergency room visit provided. 
According to the Families First Coronavirus response act, cost sharing is waived for medical visits only when 
the visit results in a test for COVID-19. The file does not show that you received a COVID-19 test, which 
means the cost sharing cannot be waived. 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 the emergency department 
visit (99282) provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a bone graft in 
conjunction with periradicular surgery (D3428). 
 
You asked the Plan to pre-approve the dental services. You say that you are disappointed with the partial 
denture that you have. You say that while you were eating, the hook that ties onto your tooth went through your 
tongue. You say that you had to go to the emergency room to have it removed. You also say that you need new 
dentures urgently. The Plan denied your request. The Plan says dentures are covered once every 5 years. The 
Plan says that the frequency limit has been reached. 
 
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 and dentures are a covered service, the 
frequency limit has been reached. The record shows that you received dentures on February 5, 2019. 
Additionally, bone graft in conjunction with periradicular surgery is not listed as a covered service. Therefore, 
we decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a bone graft in 
conjunction with periradicular surgery (D3428).