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

 
We decided that the Plan does not have to pay for physician's services provided on September 23, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 services provided on September 23, 2019.
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 the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is denied as not reasonable and necessary. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lenses. 
 
You asked the Plan to pre-approve contact lenses. You say that you cannot see at night and your eyeglasses are 
not helping you. The Plan denied your request. The Plan says the denial of authorization is correct, because 
contact lenses are not medically necessary for you. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when 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 contact lenses. Our reviewer says that 
you do not meet the Plan?s criteria for contact lenses. Our physician reviewer found that the documentation 
does not support that contact lenses are medically necessary for the enrollee in this case.  
 
We looked at the file and the Plan's rules. The requested contact lenses are not medically necessary. Based on 
this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, 
we decided that the Plan does not have to pre-approve contact lenses.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically appropriate for the 
enrollee to be transferred to an LTACH for a continuation of complex medical needs that require ongoing acute 
care. You say that the enrollee does not need to remain in the acute care hospital and would greatly benefit 
from the care that can be provided in an LTACH. The Plan denied your request. The Plan says LTACH 
services are not medically necessary. The Plan says that the enrollee's current setting of care is appropriate 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's ongoing care needs include ventilator support, surveillance laboratory 
studies, hemodialysis, tube feeding, and therapy services. The documentation does not support that the enrollee 
in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH, that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental and investigational at this time. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and 
not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve block is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider. 
 
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 covered from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only from an in-network provider. 
 
We looked at the file and the Plan's rules. The file shows that you are requesting hearing aids from an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an out-
of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on February 26, 2020, to March 
11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for specialist services provided on February 26, 2020, 
to March 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on August 3, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that this procedure was critical to have 
done. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 pay for the bone 
replacement graft (D7953) provided on August 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from 
May 19, 2020 to June 17, 2020. 
 
You asked the Plan to pay for this service. You say that this care should be covered by the Plan. The Plan 
denied your request. The Plan says the medical records show that as of May 19, 2020, the enrollees needs were 
custodial in nature and the discussion was to enter the enrollee into hospice. Medicare coverage criteria for 
SNF services were no longer met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. Based on the medical records provided, the records show 
the enrollee had advanced Alzheimer?s dementia. The care being provided as of May 19, 2020 was not skilled 
in nature. At that point the enrollee needed assistance with daily activities. The enrollee was incontinent. The 
potential for rapid decline was due to the diagnosis and not due to the need for daily skilled nursing or daily 
skilled therapy care. Medicare criteria for SNF services were no longer met. Therefore, we decided that the 
Plan does not have to pay for skilled nursing facility services provided to the enrollee from May 19, 2020 to 
June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic hereditary predictive screening testing provided on 
May 26, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing is proven accurate and effective. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because predictive 
screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There is no documentation in the record of a concern for a specific drug metabolism issue for which this testing 
was ordered. This was provided in the absence of signs/symptoms of a medical condition. This means it is 
screening in nature which is not covered by Medicare.  Therefore, we decided that the Plan does not have to 
pay for genetic hereditary predictive screening testing provided on May 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording with report 
(0297T) rendered by the out of network (OON) provider on July 22, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the external electrocardiographic recording with report (0297T) rendered by the out of network 
(OON) provider on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit. 
 
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 you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS for CLBP is covered for beneficiaries 
enrolled in a Medicare-approved clinical trial. 
 
We looked at the file and Medicare rules. The file shows that you are not enrolled in a Medicare-approved 
clinical trial for the requested TENS device. 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 
a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the requested item. You say that you need to better monitor his levels. The 
Plan denied your request. The Plan says the monitor does not meet the guideline for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from May 21, 2020, to 
May 23, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient hospital care provided from 
May 21, 2020, to May 23, 2020 was medically necessary. The Plan denied your request. The Plan says the 
inpatient hospital care provided from May 21, 2020, to May 23, 2020 was not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
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 inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided from May 21, 2020, to May 23, 2020, was not medically 
necessary. Our physician reviewer found the review indicated that all inpatient care provided after 10:32 am on 
05/21/20 to 10:33 pm on 05/23/20 was not needed on an emergent basis. The enrollee after 10:32 am on 
05/21/20 was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan 
facility for continued inpatient level of care services. The post-stabilization care services provided from May 
21, 2020 to May 23, 2020, at the non-Plan facility were not medically necessary or reasonable. The review has 
determined that the treating physician did not document (in the physician notes, on a form, or in an order) that 
the enrollee was not stable for transfer on any dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from May 21, 2020, to May 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network vascular surgeon. 
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network vascular surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral lateral nerve branch radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a service has been requested that research has not proven to be helpful. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found SI joint ablation is experimental.  More research is needed to show safety and efficacy. The use of 
radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-
term benefit than standard treatment for chronic sacroiliac joint pain. Based upon the review of the medical 
literature, radiofrequency ablation used for sacroiliac joint pain is considered experimental and not medically 
necessary - whether using traditional, cooled, or pulsed radiofrequency. The review has determined that the 
requested sacral lateral nerve branch radiofrequency ablationis 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral lateral nerve branch radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) and endodontic therapy 
(D3310). 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy. You say that these services are 
medically necessary. The Plan denied your request. The Plan says these services are not covered under the 
member's 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 the 
core buildup (D2950) and endodontic therapy (D3310).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone (J3490) 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 requested drug is intended for patient self-administration. 
 
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 testosterone (J3490) for the 
enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided by a CRNA. 
 
You asked the Plan to pay for Anesthesia for procedures on eye; lens surgery (00142). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says that the documentation supports one unit of 
Anesthesia for procedures on eye; lens surgery, (00142) which was paid. 
 
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. There is no remittance of a paid service in the file. Therefore, we decided that 
the Plan has to pay for anesthesia services provided by a CRNA.  
 
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.