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

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint injections. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found the 
records show that the enrollee has a degenerative neck condition that is compressing a nerve and causing arm 
symptoms. Facet joint injections are not indicated with nerve problems. It is not medically needed 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown. 
 
You asked the Plan to pre-approve prefabricated post and core in addition to crown. 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. 
 
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, 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 
prefabricated post and core in addition to crown.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a Smart Pill test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no evidence that shows that this is a better test than the gold standard tests. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 test. Our reviewer says that the 
requested test is considered medically reasonable and necessary in this case. Our physician reviewer found 
wireless capsule endoscopy (WCE) employs noninvasive technology to provide diagnostic imaging of the 
small bowel. The enrollee's gastroenterologist documents that the enrollee has suspected small bowel disease, 
and CT imaging has not been diagnostic. Consequently, WCE is considered medically reasonable and 
necessary for the enrollee in this case to evaluate the small bowel. 
 
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 test have been met. Therefore, we decided that the Plan has to pre-approve a 
Smart Pill test for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D6750) and pontic (D6240). 
 
You asked the Plan to pre-approve the crown and pontic. You say that you were told by the salesperson that 
these services would be covered. The Plan denied your request. The Plan says the services at issue are not 
covered benefits. 
 
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 
crown (D6750) and pontic (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you are 
not currently taking insulin three times per day. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical 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 the requested device. Our physician 
reviewer found that you are not currently taking 3 or more injectable insulin doses per day, and are not 
adjusting your insulin dose based on blood glucose readings 4 or more times per day. The records do not show 
that you preform frequent testing. You are not insulin-treated with three or more daily injections. The requested 
device is not medically reasonable or necessary to treat your diabetes condition. 
 
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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy 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 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 physical therapy services. 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 you were treated with physical therapy following anoxic 
brain injury.  
 
You have a neurological gait impairment, and history is notable for prior left knee replacement. There is a +4/5 
weakness on exam. The documentation does not support that prior physical therapy has served to provide 
sustained, significant improvement in pain and/or function and there is no indication that the residual deficits 
could not be addressed via a home exercise program. 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup and a crown for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says in general, criteria for crowns and onlays will be met only for permanent 
teeth, or primary teeth where no permanent successor is present needing multi-surface restorations where other 
restorative materials have a poor prognosis. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested services are not medically reasonable or necessary. Our physician reviewer found the 
provided x-rays reveal a minimally restored #9 with possibly an existing facial restoration. The Policy criteria 
for crown restoration requires that there be four or more surfaces compromised by either decay or trauma, and 
that 50% of the incisal edge be involved.  In this case, there is minimal damage to the tooth from prior decay or 
abrasion, and there is only about 10% of the structure compromised. There is no incisal edge involvement.  
Given the radiographic appearance of the tooth from the provided records, there is no medical necessity for a 
crown on #9. Core buildups are only indicated when a crown is to be placed and there is insufficient structure 
remaining to retain that crown. Where crowns are not indicated, there is no consideration given to a core 
buildup. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a core buildup and a crown for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal cord stimulator implant surgery. 
 
You asked the Plan to pre-approve the surgery. You say that you don't know why this was denied. The Plan 
denied your request. The Plan says that this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. It appears they had medical records 
for their denial. They have not sent any medical records for review. Therefore, we decided that 
the Plan has to pre-approve spinal cord stimulator implant surgery.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve L5-S1 RFA. We decided that the Plan does not have to pre-
approve S2 and S3 RFA.  
 
You asked the Plan to pre-approve multi-level RFA. You say that this is medically necessary. The Plan says 
that long term studies have not demonstrated that radiofrequency ablation at the sacral level is safe and 
effective. 
 
We decided that the Plan has to pre-approve L5-S1 RFA.  
 
The plan follows 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 for L5-S1 RFA. Our reviewer says that these services 
are considered medically reasonable or necessary. This is appropriate to perform for innervation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5-S1 RFA have been met. Therefore, we decided that the Plan has to pre-
approve L5-S1 RFA.  
 
We also decided that the Plan does not have to pre-approve S2 and S3 RFA. 
 
The plan follows 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 for S2 and S3 lateral branch RFA. Our reviewer says 
that these services are not medically reasonable or necessary. Our physician reviewer found that this is 
considered experimental and investigational, because of the wide variation in efficacy in the peer-reviewed 
literature. Therefore, the request for those RFAs 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 S2 and S3 RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve S2 and S3 RFA. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the requested home visits. You say that you work with the patient's assisted 
living facility and it is more convenient for the patient to have home visits instead of leaving the assisted living 
facility. The Plan denied your request. The Plan says non-plan care is generally not covered.  The plan says that 
there are network providers available to the patient for home medical visits. 
 
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. 
 
You are 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 the medical services to be 
provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. 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. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy 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 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 physical therapy services. 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 enrollee has been treated with physical therapy for neck 
and low back pain due to cervical and lumbar radiculitis.  
 
Treatments have included modalities, strengthening, and manual therapy. Functionally, the enrollee required 
contact guard assistance for mobility and transfers. The documentation does not support that prior physical 
therapy has served to provide sustained, significant improvement in pain and/or function and there is no 
indication that residual deficits could not be addressed via a home exercise program. 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the requested home visits. You say that you are contracted with the Assisted 
Living Facility where the member resides.  You stated that it is preferable for a patient to have the services 
delivered to them in their home. The Plan denied your request. The Plan says there are plan providers available 
who can provide home visits for this patient. 
 
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. 
 
You are 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 the medical services to be 
provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
You asked the Plan to pay for the allowance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 HCPCS code S9986 is "Not medically necessary service (patient is aware that service not medically necessary)." We find that HCPCS code S9986 is not supported in the medical record. Specifically, when this code is used, the request cannot be covered. Based on this information, we decided that Medicare rules for coverage of the allowance have not been met. Therefore, we decided that the Plan does not have to pay for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2950) 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 D2950 is not a covered service. 
 
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 services (D2950) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humalog 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 this is a self-administered drug. 
 
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 Humalog for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One (J7326). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Monovisc and Orthovisc. 
 
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 Gel-One (J7326). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found this appeal considers the 
request for Gel-One for the treatment of osteoarthritis in bilateral knees. The enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc.  Step Therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered. Without the support of the documentation, Gel-One is not approved as step criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One (J7326) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gel-One.