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

 
We decided that the Plan has to pre-approve bilateral lumbar medial branch blocks (MBBs) (64493 x 2, 64494 
x 2). 
 
You asked the Plan to pre-approve the MBBs. You say that the MBBs are medically necessary. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are medically necessary. Our physician reviewer found the provided documentation indicates 
that the enrollee started physical therapy in July of 2022. Therefore, the reviewer found that the request for the 
MBBs is 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 MBBs have been met. Therefore, we decided that the Plan has to pre-
approve bilateral lumbar medial branch blocks (MBBs) (64493 x 2, 64494 x 2).  
 
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 pay for the three-year eye club membership on April 29, 2022. 
 
You asked the Plan to pay for the three-year eye club membership. You say that the membership includes three 
eye exams, and you would like to be reimbursed. The Plan denied your request. The Plan says the service is not 
a covered benefit and does not qualify for the allowance.  
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 does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the three-year eye club membership is not a covered 
benefit and does not count towards the $250 allowance. Based on this information, we decided that the Plan's 
rules for coverage of the three-year eye club membership have not been met. Therefore, we decided that the 
Plan does not have to pay for the three-year eye club membership on April 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these sessions are medically necessary. 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. 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's current needs do not require the unique skills of a 
professional therapist. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes (99239) provided on December 10, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the services were provided to the enrollee in good 
faith. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes (99239) provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. 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 pay for the moderate sedation services 
rendered on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77049). 
 
You asked the Plan to pre-approve an MRI of the breast. You say that an ultrasound was recommended and 
completed. You also say that a bilateral breast MRI is now recommended. The Plan denied your request. The 
Plan says this service is not reasonable and necessary under Medicare guidelines. 
 
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 breast. Our reviewer says 
that an MRI of the breast is not reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has undergone breast augmentation. Our reviewer found that the record 
indicates that the enrollee does not have physical examination evidence, ultrasound, or mammographic 
evidence of rupture. Our physician reviewer also found that the requested service is not medically necessary 
and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 an MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve, Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. The Plan denied your request. The Plan says this 
procedure is considered investigational. There is lack of scientific evidence regarding safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the thermal destruction of intraosseous basivertebral nerve, Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 2, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 
  We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 2, 2022, billed with multiple codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve forty-four (44) fractions of PBT (CPT code 77399). 
 
You asked the Plan to pre-approve the PBT. You say that the PBT is medically necessary. The Plan denied 
your request. The Plan says the enrollee's doctor has requested a greater number of daily treatment doses than is 
needed. The Plan states that twenty-eight (28) daily treatment doses are allowed for the enrollee's treatment 
course; therefore, the request for more than 28 doses exceeds this limit. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the most recent American Urological Association (AUA) guidelines state that PBT offers no 
clinical advantage over other forms of definitive 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 the PBT have not 
been met. Therefore, we decided that the Plan does not have to pre-approve forty-four (44) fractions of PBT 
(CPT code 77399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental and is non-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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found interspinous devices are considered experimental at this time. More research is needed to show 
safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided May 25, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not feel the $40 
copay should be charged because the provider is just a Nurse Practitioner. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/specialist visits or consultations.  
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist visits or consultations 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 a specialist office visit provided May 25, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided June 21, 
2022, to August 2, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you did not realize the services 
would not be covered. You cannot afford these bills. The Plan denied your request. The Plan says the claim has 
been processed correctly as the benefits exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes. The Plan offers a medical nutrition therapy benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
maximum of 3 hours of ne on one counseling services during your first year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage for medical nutrition therapy.  Therefore, we 
decided that the Plan does not have to pay for the medical nutrition therapy services provided June 21, 2022, to 
August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454) for chronic knee pain. 
 
You asked the Plan to pre-approve the injection. You say that the requested service is covered by Medicare if 
the enrollee has had a total knee replacement with continued issues after surgery. You also say that the enrollee 
has had a total knee replacement with increasing and current pain. The Plan denied your request. The Plan says 
the requested service 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 injection. Our reviewer says that the 
requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested injection is considered experimental and investigational. Therefore, the 
reviewer found that the request 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454) for chronic knee pain.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 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 additional visits are not medically necessary or reasonable based 
on the review of documentation by the physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
for pneumonia. ABG was consistent with acute on chronic hypercarbic respiratory failure. Spirometry in the 
hospital showed mild obstructive lung disease with FEV1 70% predicted, not severe enough to account for 
chronic CO2 retention. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. If the 
enrollee has chronic CO2 retention, documented on ABG done while stable as an outpatient, she may benefit 
from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac magnetic resonance imaging (MRI) for 
morphology and function without contrast (75557). 
 
You asked the Plan to pre-approve the MRI. You say that you cannot pay out of pocket for this service. You 
say that your provider requested an MRI be done. You also say that you are not sure why this is being denied. 
The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MRI have been met. Specifically, the file does not include medical records to support that the requested service is medically necessary. The 
record shows that the Plan requested this information, but nothing was received. Therefore, we decided that the 
Plan does not have to pre-approve cardiac magnetic resonance imaging (MRI) for morphology and function 
without contrast (75557).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 
You asked the Plan to pre-approve Monoferric. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Monoferric. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Monoferric. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no 
indication that the Plan's required drugs would likely be less effective and/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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).