Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not indicated for the enrollee. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee's needs could be met with outpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
reviewer says that the criteria for inpatient care have not been met in this case. Our physician reviewer found 
based on the records provided, it does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness 
to self or others, perceptual disturbance including delusions, auditory or visual hallucinations and it is not 
expected this enrollee would improve in a reasonable period of 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 inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second medial branch block (MBB). 
 
You asked the Plan to pre-approve a second medial branch block. 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 follows Medicare rules. Medicare rules say that a second confirmatory MBB is allowed if 
documentation indicates the first MBB produced greater than 80% relief of primary (index) pain and duration 
of relief is consistent with the agent employed. 
 
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 second medial branch block. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. he had diagnostic L3-L4 
bilateral medical branch block (MBB) performed on August 11, 2020. The follow up phone call of August 12, 
2020 states that the enrollee got 50% pain relief from the MBB. The enrollee did not achieve 80% pain relief 
from the diagnostic MBBs. Therefore, the injection is considered negative and the enrollee does not meet 
criteria for the additional 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 a second medial branch block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a second medial branch block (MBB).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the upper partial denture. You say that you have health problems. You say 
that you would like to be able to eat. You also say that you need these procedures. The Plan denied your 
request. The Plan says the crown is not medically necessary. The Plan says that the partial upper denture would 
not be an essential service based on the policy guidelines and plan benefit coverage. 
 
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 upper 
partial 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 upper partial denture. Our reviewer 
says that the upper partial denture does not meet the criteria for coverage. Our physician reviewer found that 
with the lower partial denture in place there is a full complement of lower teeth. In this case, there would be at 
least eight points of posterior contact with the lower partial denture in place. Given the Plan limitations, there 
would be no necessity for the upper partial denture. 
 
 
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 upper partial denture have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upper partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection services. 
 
You asked the Plan to pre-approve injection services. 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 follows Medicare rules. Medicare rules say that injection services are only covered for certain 
indications. 
 
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 injection services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain. The enrollee had trials of physical therapy, 
nonsteroidal anti-inflammatory drugs, and oral medications.  The code requested is for a facet block, but there 
is no level specified, is it bilateral or unilateral, diagnostic or therapeutic. There is a critical lack of detail in the 
request and therefore, the request is deemed 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 injection services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bag hooks. 
 
You asked the Plan to pre-approve the hooks. You say that this is medically necessary. The Plan denied your 
request. The Plan says bag hooks are not primarily medical in nature. 
 
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 bag hooks.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve the transportation. You say that this is medically necessary. The Plan denied 
your request. The Plan says you are not bed confined, as you are able to sit in a wheelchair. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
You are not bed-confined. Based on this information, we decided that Medicare rules for coverage of the 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-
emergency ambulance transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's service provided on the date of service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiogram. 
 
You asked the Plan to pre-approve a stress echocardiogram. 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 follows Medicare rules. Medicare rules say that stress echocardiograms are only covered for certain 
indications. 
 
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 stress echocardiogram. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have increased coronary risk but very atypical symptoms, a normal 
cardiovascular physical exam and no reported electrocardiogram. In this circumstance the symptoms are non-
exertional and very atypical so not likely to be of cardiac origin. Therefore, you do 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 a stress echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stress echocardiogram.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the upper and lower partial denture. You say that you do not like the way 
your current dentures feel in your mouth. The Plan denied your request. The Plan says partial dentures are 
covered once every 5 years. The Plan says the frequency limit for partial dentures 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 partial dentures are a covered 
service, the frequency limit of once every 5 years has been reached. The record shows the Plan previously paid 
for this service on December 22, 2017. Therefore, we decided that the Plan does not have to pre-approve an 
upper partial denture (D5213), and a lower partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services rendered on December 11, 2019. 
 
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 six units of procedure code J9217 is not supported. 
 
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 J9217 is leuprolide acetate (for depot suspension), 7.5 
mg. 
 
We find that CPT code J9217 is not supported in the medical record. Specifically, there is no documentation of 
the dosage administered, as defined in the billed service. 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 drug services rendered on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that you require the device. The 
Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic 
pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch Ultra test strips. 
 
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the preferred product. 
 
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 strips. Our reviewer says that the 
requested strips is not considered medically reasonable and necessary in this case. Our physician reviewer 
found upon a review of the records provided, there was no reported explanation for not using the preferred 
testing strips. There was no evidence of a failure or contraindication to the preferred strips to justify this 
request. Generally, the glucometers and testing strips are considered equally effective. Therefore, this request 
for One Touch Ultra Strips will be considered not medically based on the records provided. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve One Touch Ultra test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on the date of service. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because this was a telehealth visit. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialist visit, including telehealth services.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the right hip and knee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found a written order by the 
requesting physician is required by CMS for any imaging study. Additionally, medical necessity has not been 
established since six weeks of conservative therapy has not occurred. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the right hip and knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve right knee genicular radiofrequency ablation. 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 follows Medicare rules. Medicare rules say that injection services are only covered for certain 
indications. 
 
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 right knee genicular radiofrequency 
ablation. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found you have chronic right knee pain status post total knee 
replacement. You have tried physical therapy and a home exercise program. You take opiates for the pain. You 
underwent diagnostic genicular blocks and had significant pain relief but it was short lived. The requested is 
considered an experimental/ investigational technique that is the subject of on-going clinical trials. Therefore, 
you do 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 right knee genicular radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right knee genicular radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on the date of service. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and 
you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 $35 
copayment for each specialist office visit, including telehealth services.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on March 18, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that EGD's are considered preventative and 
you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $390 
copayment for surgery services provided in an outpatient hospital facility.  
 
You received an EGD on March 18, 2020. An EGD is considered an outpatient surgical procedure, and is not 
considered preventative. Therefore, you are responsible to pay $100, which is less than the $390 copayment.  
 
You have been asked to pay $100 for an EGD. An EGD falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on March 18, 2020.