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

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. You say that you are having increased pain which was 
previously helped by an SI joint injection. You feel this should be covered. The Plan denied your request. The 
Plan says there is no trial of physical therapy or other conservative measures. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections may be covered for SI joint 
generated pain when conservative treatments have failed.  
 
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 SI joint injection. Our reviewer says 
that the requested treatment does not meet the LCD criteria and is not shown to be medically necessary. Our 
physician reviewer found the enrollee has chronic low back pain. She has an intra-thecal pump which is 
working. She had a Left SI joint injection in 2019 which provided excellent relief and would like it repeated. 
She has not had recent conservative therapy such as Physical therapy or other physical medicine therapies. 
 
The patient has not had a recent trial of conservative therapies as required by the LCD. Therefore, at this point, 
the request 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 the SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two excisions of benign lesions (D7410 x2). 
 
You asked the Plan to pre-approve the excisions of benign lesions. You say that you have a lesion on the top of 
your mouth that is causing you pain and discomfort. You also say that you need this procedure done as quickly 
as possible, and would like the Plan to pay for it. The Plan denied your request. The Plan says this service is not 
covered under your benefit package. 
 
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 two 
excisions of benign lesions (D7410 x2).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for assisted living services provided by an out of network provider on 
February 12, 2020 to March 11, 2020. 
 
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
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 failed to send us the correct 2020 Evidence of Coverage. Therefore, 
we decided that the Plan has to pay for assisted living services provided by an out of network provider on 
February 12, 2020 to March 11, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93970) and abdominal x-ray (74018) 
provided on March 22, 2020. 
 
You asked the Plan to pay for the extremity study and abdominal x-ray. You say that you would like 
reconsideration because this claim denied as a duplicate in error. The Plan denied your request. The Plan says 
these charges are duplicates of charges considered on a different claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We find that CPT codes 93970 and 74018 are not supported in the record. Specifically, the record does not 
indicate that these services were rendered more than once. The documentation shows that CPT codes 93970 
and 74018 were previously processed and paid. Based on this information, we decided that Medicare rules for 
coverage of the extremity study and abdominal x-ray have not been met.  
Therefore, we decided that the Plan does not have to pay for the extremity study (93970) and abdominal x-ray 
(74018) provided on March 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. 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 a covered 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. 
 
The genetic testing at issue in this appeal is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that all your labs have been done with this 
doctor. The Plan denied your request. The Plan says there are multiple in-network providers within 10 miles of 
the member's residence. 
 
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 
an outpatient surgery 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 pre-approve the prefabricated post and core and crown. 
 
You asked the Plan to pre-approve the prefabricated post and core and crown. You say that you are upset over 
the denial of services. The Plan denied your request. The Plan says the services 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 the 
prefabricated post and core and crown.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual field testing (0379T). 
 
You asked the Plan to pre-approve visual field testing. You say that this is medically necessary. 
 The Plan denied your request. The Plan says this is noncovered. 
 
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 visual field testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of Nonexudative age-related macular degeneration, bilateral, 
intermediate dry stage. It is documented the he was instructed on the use of the Amsler grid and to call the 
office with any changes. The documentation does not show the requested testing is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of visual field testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve visual field testing (0379T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve X-Ray examinations. 
 
You asked the Plan to pre-approve X-Rays. You say that these X-Rays are needed. The Plan denied your 
request. The Plan says the denial of authorization for these tests is correct, because the enrollee's primary care 
provider did not order these tests. 
 
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 X-Rays. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are bedridden with chronic airway problems with marked secretions. Your treating 
physician who has evaluated you does not feel that these X-Rays are indicated and has recommended 
tracheostomy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of X-Rays have not been met. Therefore, we decided that the Plan does not have to 
pre-approve X-Ray examinations.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown, 
prefabricated abutment, endosteal implant, and bone replacement graft for ridge preservation. 
 
You asked the Plan to pre-approve the implant supported crown, prefabricated abutment, endosteal implant, 
and bone replacement graft. You say that you have an under bite and without getting the implant, it will cause 
you to not be able to chew any food. You also say that without these services, it will cause bone loss. The Plan 
denied your request. The Plan says your Plan does not cover these procedures. 
 
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 an 
implant supported porcelain/ceramic crown, prefabricated abutment, endosteal implant, and bone replacement 
graft for ridge preservation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a total knee arthroplasty to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necesasry. The Plan denied your 
request. The Plan says this denied due to the provider being 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 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 for a total knee arthroplasty 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 preapprove a pneumatic compression device (E0651). 
 
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 show that at least 4 weeks of conservative 
therapy were documented. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 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 compression stockings, elevation and exercise.  
 
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 conservative therapy demonstrating failed response to compression stockings, elevation 
and exercise.. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you use a cane to walk and are not able 
to walk quickly to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system for the 
enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says 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 the monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not check blood sugar 3 or more times per day. This has been requested for 
convenience of patient and family and does not meet standard criteria for use. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitoring system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a reline of a complete 
maxillary denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and reline of a complete maxillary denture. 
You say that you understood that the dentures you currently have were starting dentures, and you would 
receive permanent ones after 6 months. You also say that your current dentures do not fit correctly. The Plan 
denied your request. The Plan says reline of a complete maxillary denture is not covered. The Plan also says 
that your benefit for complete maxillary dentures has been exhausted. 
 
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, reline of a complete maxillary denture 
is not among those covered under this benefit. The contract clearly states that complete dentures are limited to 
one upper complete and one lower complete denture every five years. The record shows that you received an 
immediate maxillary denture on July 3, 2019 and your complete maxillary dentures benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and a reline of a 
complete maxillary denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to the enrollee by an out-of-network provider 
on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cooled radiofrequency ablation 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 non-thermal RF modalities for facet joint denervation including chemical, low grade 
thermal energy (less than 80 degrees Celsius), laser, and pulsed RF are not covered. 
 
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 the requested services remain experimental at this time. The review has determined that the requested 
cooled radiofrequency ablation 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cooled radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the One Touch Ultra Blue blood glucose/reagent test 
trips for the enrollee. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence of a trial of the preferred strips. 
 
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 test strips. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered a test strip. If there were problems with the formulary test strip, 
this would be different. 
 
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 strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the One Touch Ultra Blue blood glucose/reagent test trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable sensor (A9276). 
 
You asked the Plan to pre-approve the sensor. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says non-therapeutic CGM sensors are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that only therapeutic CGMs are covered by Medicare 
under the DME benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sensor have not been met. Specifically, therapeutic CGMs are coded as K0554 and their 
supplies are coded as K0553. The requested monitor/sensors are not therapeutic and therefore non-covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a disposable sensor (A9276).
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 have been approved for 
compression stockings in the past. The Plan denied your request. The Plan says the denial of authorization for 
these items is correct, because these compression stockings are not covered by Medicare. 
 
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.