Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy visits. 
 
You asked the Plan to pre-approve additional speech therapy visits. You say that you are requesting 31 visits in 
addition to the 10 approved. 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 additional speech 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 the 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 additional speech therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional speech therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta. 
 
You asked the Plan to pre-approve the Vyzulta. You say that the enrollee is stable on Vyzulta, and needs to 
continue treatment. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition by Medicare 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 Vyzulta.  
 
Benefits for the Vyzulta 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the upper and lower partial denture. We decided that the Plan does 
not have to pre-approve the extractions.  
 
You asked the Plan to pre-approve the upper and lower partial denture. The Plan says that medical necessity 
cannot be determined. 
 
We decided that the Plan has to pre-approve the upper and lower partial denture.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upper and lower partial denture and 
extractions. Our reviewer says that the dentures are reasonable and necessary. Our physician reviewer found 
the documentation submitted reveals multiple missing teeth in the maxillary and mandibular arches. Our 
reviewer says that replacement of the missing teeth with removable partial dentures is reasonable and necessary 
to return the patient to good masticatory function. Therefore, we decided that the Plan has to pre-approve the 
upper and lower partial denture.  
 
We also decided that the Plan does not have to pre-approve the extractions. 
 
Our reviewer says that the extractions are not medically necessary. Our reviewer says that the extractions could 
be performed by lesser means. Therefore, we decided that the Plan does not have to pre-approve the 
extractions. 
 
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 waive the copayment for the established patient office or other 
outpatient visit (99213) provided on March 4, 2020. 
 
You asked the Plan to waive the copayment for the established patient office or other outpatient visit. You say 
that you need The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $40 copayment for the established patient office or other outpatient visit. The 
services provided fall within the consultation, diagnosis, and treatment by a specialist benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the established patient office or other outpatient visit 
(99213) provided on March 4, 2020.  
 
The QIC read your letter and knows that you may have a quality of care concern. The QIC ++cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review. 
 
Your complaint about the contracted provider allegedly violating your privacy is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 23, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Local anesthesia or minimal conscious sedation may 
be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. 
Documentation must clearly establish the need for such sedation in the specific 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 pay for the anesthesia services. Our reviewer says 
that the documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain and lumbar radiculopathy. There is no listing 
of weight, height or BMI. There is no NPO status listed. The enrollee received a transforminal epidural steroid 
injection. The anesthesia record does not meet the standard of care as several essential elements are not present. 
The ASA committee on Pain management as well as several other learned societies have specifically stated that 
IV sedation may interfere with the safe performance of an epidural steroid injection. Therefore, the enrollee did 
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 the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services provided on June 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says the 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 additional 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 the requested additional therapy is not generally 
accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy for 
this condition and it does not appear that the patient requires the unique skills of a professional therapist to 
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The patient has been trained in an independent exercise 
program in the past and the patient's current barriers per therapy notes appear to be anxiety. Therapy 
recommends referral to mental health and pain management. The specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 
current condition or to prevent or slow further deterioration. 
 
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 physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ten (10) additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy, and 
daily oversight by a physician in an inpatient setting. The Plan denied your request. The Plan says the enrollee's 
medical condition is not complex, and does not require close supervision by a rehab physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that the enrollee is independent with eating, standby assist for grooming, moderate assist for grooming, 
minimal to maximal assist for dressing, and minimal assist for toileting. The enrollee does not require the 
intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee and billed 
under codes G0483 and 80307. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the documentation submitted did not include a valid physician 
order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be 
performed. It is noted multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary provided the documentation 
required by Medicare to support the services billed. In this case, the records provided do not support the 
services billed due to an incomplete physician's order.  Medicare rules for coverage of this claim have not been 
met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee 
and billed under codes G0483 and 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections, lumbar/sacral, 1 level (64493) and facet 
injections, lumbar/sacral, 2nd level (64494). 
 
You asked the Plan to pre-approve facet injections, lumbar/sacral, 1 level and facet injections, lumbar/sacral, 
2nd level. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy 
(includes RF and microwave technologies) are medically necessary when certain criteria is met. 
 
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 injections, lumbar/sacral, 1 level 
and facet injections, lumbar/sacral, 2nd level. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found in this case, there is no documentation provided indicating the prior injection 
provided greater than 50 % pain relief for at least 3 months. The review has determined that the enrollee does 
not meet the coverage criteria. 
 
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 injections, lumbar/sacral, 1 level and facet injections, lumbar/sacral, 2nd 
level have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections, 
lumbar/sacral, 1 level (64493) and facet injections, lumbar/sacral, 2nd level (64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member does not have a medically complex situation, 
including comorbidities that will require ongoing acute care and complex nursing needs and close physician 
supervision. 
 
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. The patient 
appears to be worsening which requires additional short term acute care services, which can be safely 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the foot. 
 
You asked the Plan to pre-approve an MRI of the foot. You say that the requested MRI of the foot is medically 
necessary. The Plan denied your request. The Plan says the requested MRI of the foot is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the foot. Our reviewer says 
that the requested MRI of the foot is not medically necessary. Our physician reviewer found this enrollee 
presented with a 1 to 2-week history of posterior to lateral left foot aching pain and swelling after hiking. 
Clinical exam findings evidence tenderness to palpation over the fifth metatarsal midshaft and slightly 
proximal with moderate edema. She has been using a CAM walker boot for ambulation. Under consideration is 
a request for MRI of the left foot. Current evidence based medical guidelines support x-rays of the foot as the 
first imaging study in a suspected stress fracture. The records do not evidence that x-rays have been obtained 
and are normal or equivocal to support additional imaging at this time. Therefore, this request for MRI of the 
left foot 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 an MRI of the foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an MRI of the foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve the requested services. You say that none of the general dentist are willing 
to do a tooth extraction. The Plan denied your request. The Plan says your plan only covers services provided 
by a participating general dentist. 
 
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 file shows that a consultation and extraction were requested. We looked at the file, and Medicare rules. 
Dental services are only covered when performed by a participating general dentist. Based on this information, 
we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral appliance (E0486) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. You say that the oral appliance is necessary. The Plan denied 
your request. The Plan says there are providers in-network that can provide the oral appliance. 
 
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 
oral appliance (E0486) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine patches. 
 
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 self-administered drugs are not covered. 
 
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 Buprenorphine patches.  
 
Benefits for these services 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has failed NSAIDs and a home exercise 
program. The Plan denied your request. The Plan says the enrollee has not tried and failed conservative therapy 
and steroid injections. 
 
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 Orthovisc. Our physician reviewer 
found that the enrollee was diagnosed left knee osteoarthritis, who had tried and failed NSAIDs and home 
exercises. The Plan requires a trial of conservative therapy and steroid injections before they will approve the 
requested drug. The provided records did not show that the enrollee has tried and failed all required 
therapies/injections. The documentation does not show that the plan's requirements are likely to be less 
effective, or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.