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

 
We decided that the Plan does not have to pre-approve percutaneous revascularization of right lower extremity. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee does not have documented 
lifestyle limiting claudication, ischemic rest pain, or tissue loss.  There does not appear to be any effort at 
conservative treatment such as antiplatelet therapy, recommendations regarding smoking cessation, guidelines 
regarding a walking regimen, or consideration of other medical treatments. The services are not reasonable or 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous revascularization of right lower extremity.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea genicular nerve block.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the requested use of this treatment is considered investigational.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 requested services. Our physician reviewer found that the enrollee has chronic left knee pain. She has undergone previous left knee Euflexxa injections three times, and a cortisone injection to the left knee. She also received left genicular nerve blocks. The effectiveness of Genicular nerve blocks to treat knee pain has not been established. Genicular nerve blocks are considered experimental/investigational in nature. As such, left Genicular nerve block to treat knee pain is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approvea genicular nerve block.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the BLS non-emergency ambulance service 
(A0428) and ground mileage (A0425) provided August 21, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment is too 
high and you cannot afford this. You have a bunch of medical bills and you thought the insurance would help 
pay for this. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
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 $225 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $225 for these 
services. 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 the BLS non-emergency ambulance service 
(A0428) and ground mileage (A0425) provided August 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to get to 
appointments. The Plan denied your request. The Plan says that this benefit is exhausted. 
 
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 forty-eight (48) 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 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick female external catheters for the enrollee. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this is not considered reasonable and necessary by 
Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve Purewick female external 
catheters for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Irbesartan for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Irbesartan for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing services. 
 
You asked the Plan to pre-approve additional services. You say that the enrollee's comorbidities require the 
attention of a skilled nurse at least 2 times a week. The Plan denied your request. The Plan says the enrollee's 
wounds are not large or complex. 
 
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. 
 
The file shows that 18 home health skilled nursing visits were requested. The Plan has agreed to pre-approve 
10 visits. 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 additional services. Our 
physician reviewer found that there is no documentation that the eight denied home health skilled nursing visits 
are required to effectively provide treatment to improve the enrollee's condition, or to perform a maintenance 
program to maintain the enrollee's condition or prevent deterioration.  
 
 
The ten approved visits appear adequate for her condition. Her wounds measure 0.5x3.8x0.2 cm and 2.5x2x0 
cm and her wound care involves normal saline cleansing, pat dry, Xeroform to wound bed with Telfa and 
gauze and ACE wrap. This is not complex wound care. Therefore, the additional visits are not medically 
reasonable and necessary.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says you were approved for repairs, but not a new chair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found your current 
power wheelchair needs repairs. It is unclear why you are unable to use a manual wheelchair, given your full 
range of motion and strength level, and coordination in the upper extremities. Your current wheelchair can be 
repaired and would be able to meet your needs. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group two power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings. The Plan 
denied your request. The Plan says elastic stockings are not covered because they are non-reusable supply 
items and not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression devices and cold pad with 
pump (E0676, E0673, E0218). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that this would be cheaper than 
staying in the hospital to prevent blood clots. The Plan denied your request. The Plan says the pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to preapprove a pneumatic compression devices and cold pad with pump (E0676, 
E0673, E0218).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation (99242) and chiropractic 
manipulative treatment (98942). 
 
You asked the Plan to pre-approve an office consultation (99242) and chiropractic manipulative treatment 
(98942). You say that the requested chiropractic manipulative treatment (CMT (98942) and office consultation 
(99242) are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested chiropractic manipulative treatment (CMT) (98942). The Plan says that office 
consultations (99242) are not covered by Medicare or the Plan when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic manipulative treatment 
(98942). Our reviewer says that the enrollee does not meet criteria for the requested chiropractic manipulative 
treatment (CMT) (98942). Our physician reviewer found the enrollee is with a history of upper back pain, 
chronic, right sided low back pain, chronic right hip pain, trochanteric bursitis of the right hip and primary 
osteoarthritis of the right hip. 
 
X-rays of the lumbar spine, dated 9/15/20, reveal scoliosis and degenerative changes, minimal anterolisthesis of 
L1, L2, L3, and L5 and facet disease in the lower lumbar spine. These results do not reveal evidence of a 
subluxation. The submitted medical office visit note, dated 8/4/20, reveals back/spine findings of posterior 
tenderness flexion, distance of finger to ground of 20 cm., paravertebral muscle spasm, rotation and SLR 
{straight leg raise}, elevated/supine, negative. These findings do not reveal evidence of subluxation per 
Medicare guidelines. Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Medicare also says that office consultations 
(99242) are not covered when provided by a chiropractor. Based on this information, we decided that Medicare 
rules for coverage of an office consultation (99242) and chiropractic manipulative treatment (98942) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an office consultation (99242) and 
chiropractic manipulative treatment (98942).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4K scoring lab testing for the enrollee. 
 
You asked the Plan to pre-approve 4K scoring lab testing. You say that this screening is medically necessary 
based on a rise in the enrollee's PSA score. The Plan denied your request. The Plan says Medicare coverage 
criteria are not met. The Plan states this testing is investigational and is not covered by Medicare.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. While prostate cancer screening tests are covered, 4K scoring is not 
currently among those covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
4K scoring lab testing for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a dorsal root ganglion stimulator. 
 
You asked the Plan to pre-approve neurostimulator. You say that the enrollee has chronic intractable pan which 
is unable to be surgically addressed and is not helped by medication. The Plan denied your request. The Plan 
says the denial of authorization for this procedure is correct, because this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve neurostimulator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of a dorsal root ganglion stimulator for diabetic neuropathy is considered 
experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurostimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve implantation of a dorsal root ganglion stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 11. 
 
You asked the Plan to pre-approve the dental service. You say that you believe an exception to coverage should 
be granted. You say that the crown was not initially done correct. You say that the crown does not fit your bite 
and prevents you from wearing your mouth guard for bruxism. You also say that you are not able to get a new 
partial because the crown is not stable. The Plan denied your request. The Plan says crowns are covered once 
per tooth 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are a covered service, the 
frequency limit of once per tooth every 5 years has been reached. The record shows that the Plan previously 
paid for a crown for tooth # 11 on December 30, 2019. Therefore, we decided that the Plan does not have to 
pre-approve a crown (D2740) for tooth # 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that your dentures were in your purse when it was 
stolen. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan 
says that the frequency limit for 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 lower dentures are a covered 
service, the frequency limit of once every 5 plan years has been reached. The record shows that the Plan 
previously paid for a lower denture that you received on April 9, 2019. Therefore, we decided that the Plan 
does not have to pre-approve a complete lower denture (D5120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 additional physical therapy visits.You asked the Plan to pre-approve10 physical therapy visits. You enclosed a letter from the provider and your family physician. You say that the provider faxed information stating you are making progress.The Plan denied your request. The Plan says additional visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 10 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy for this condition and were trained in an independent exercise program.Our reviewer says thatthe unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.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 physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection. 
 
You asked the Plan to pre-approve facet joint injection. 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 facet joint injections 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 facet joint injection. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found although the enrollee has a history of chronic neck and back pain, there is no 
documentation of conservative care for a minimum of six weeks directed to the neck. The requested procedure 
is supported for predominantly axial pain that is not associated with radiculopathy or neurogenic claudication.  
The office notes indicate the enrollee has chronic neck pain with radiation into the right and left shoulders. The 
most recent medical records submitted from date of service August 13, 2020 do not document a physical exam. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic colonography (CTC or CT 
colonography) screening. 
 
You asked the Plan to pre-approve CT colonography screening. You say that your doctor recommended that 
you have this test. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because screening CT colonography is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that screening CT colonography is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT colonography screening have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic colonography (CTC or CT colonography) screening.