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

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the injections. You say that you do not have transportation to go to physical 
therapy every week. You say that you were diagnosed with arthritis. You also say that you were told physical 
therapy would not help it. The Plan denied your request. The Plan says the requested injections 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 has trialed a minimum 
of 3 months with documented failure to respond to noninvasive conservative care management. 
 
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 injections. Our reviewer says that 
the requested facet joint injections are not medically necessary. Our physician reviewer found the provided 
documentation does not support that you have trialed any non-invasive conservative care management. 
Therefore, the reviewer found that the requested facet joint injections are not medically necessary 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64490, 64491).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for observation care provided on October 24, 2021. 
 
You asked the Plan to pay for observation care. You say that the Plan clearly states that an ambulance can 
deliver you to the nearest hospital in an emergency situation and you did not choose the providers. The Plan 
denied your request. The Plan says that the provider is out-of-network and authorization was not obtained prior 
to services being rendered. 
 
The Plan must follow Medicare rules. Medicare says that plans must pay for emergency and urgently needed 
services. The prudent layperson would have believed that someone suffering from a heart attack would have an 
emergent need for services. This was a clear emergency situation. The plan must provide care outside of the 
network when network care is unavailable. You had no choice where to receive services when the ambulance 
was called. Based on this information, we decided that Medicare rules for coverage of the hospital services 
have been met. Therefore, we decided that the Plan has to pay for observation care provided on October 24, 
2021. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Riluzole tablets. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Riluzole tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of a MyoPro Motion G powered orthosis 
(L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G powered orthosis. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
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 a MyoPro Motion G powered orthosis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific 
evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term 
outcomes for the enrollee. There is insufficient evidence in the literature that the requested device will increase 
participation in bimanual activities.  
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 MyoPro Motion G powered orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the use of a MyoPro Motion G powered orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on March 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery payment for the procedure (47562) provided on the same date. 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 pay for the services (99213) provided on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a four-week trial of daily, regular, and multiple hour use of 
the basic device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as the records do not document trial and failure of a basic/standard pneumatic compression pump, 
then it cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 23, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
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 Emgality.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic colonoscopy provided on May 
11, 2022. 
 
You asked the Plan to waive the deductible for diagnostic colonoscopy. You say that this should be covered. 
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 $400 
deductible for Outpatient procedures and services. 
 
You have been asked to pay a $400 deductible for diagnostic colonoscopy. This item/service falls within the 
Outpatient procedures and services 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 deductible for 
diagnostic colonoscopy provided on May 11, 2022.
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 the enrollee clearly meets criteria for a 
medically appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee should 
remain at the current facility until the enrollee's condition is stable for transfer to an alternate level of care such 
as a skilled nursing facility (SNF) or until the clinical circumstances change such that LTACH may be 
reconsidered. The Plan denied your request. The Plan says the enrollee's status is stable, improving and is 
receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that 
cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. The plan will continue to cover medically necessary acute and critical care at the current 
facility until the enrollee's condition is stable for transfer to an alternate level of care such as a skilled nursing 
facility (SNF) or until the clinical circumstances change such that LTACH may be reconsidered. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH and is receiving appropriate care at the present acute care hospital. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 cervical facet joint injections. 
 
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 medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria 
are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of neck pain 
due to cervical spondylosis. She has been treated with medical therapy, including opiates and cervical facet 
injections with good relief of greater than 85 percent. The most recent injections were on July 12, 2022. She 
refused radiofrequency ablation (RFA); however, there is no documentation as to why RFA cannot be 
performed. The records do not support that the facet injections are reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical facet joint injections.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a stellate ganglion block (code 64510) provided on March 22, 2022. 
 
You asked the Plan to pay for a stellate ganglion block. You say that the stellate ganglion block is medically 
necessary. The Plan denied your request. The Plan says that the stellate ganglion block is experimental or 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a stellate ganglion block. Our reviewer says 
that the requested stellate ganglion block is considered medically reasonable and necessary in this case. Our 
physician reviewer found a sympathetic nerve block is standard of care for sympathetic maintained pain. The 
procedure was 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 a stellate ganglion block have been met. Therefore, we decided that the Plan has 
to pay for a stellate ganglion block (code 64510) provided on March 22, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flex-Walk system and protective outer surface 
covering for a prosthesis. 
 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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic additions are covered when specific 
criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee requires covering system protection against unusually harsh environment situations where it is 
necessary to protect the lower limb prosthesis beyond that afforded by a standard cover. The Flex-Walk system 
exceeds the enrollee's medical needs, as the records do not support that his functional goals are at a K3 
ambulation level. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Flex-Walk system and protective outer surface covering for a prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Smartview strips (A4253). 
 
You asked the Plan to pre-approve diabetic supplies. You say that the enrollee has a diagnosis of type 2 
diabetes, and she has not failed any other diabetes testing supplies. The Plan denied your request. The Plan says 
the enrollee does not meet coverage criteria for the requested strips. 
 The Plan must follow Medicare rules. Medicare rules say the enrollee must meet criteria for approval of non-
preferred testing supplies. 
 
We looked at the file and Medicare rules. The records show that the enrollee has not failed any other testing 
supplies. The EOC confirms that the enrollee must try and fail the preferred glucose test strips and/or have the 
prescriber provide information that shows why the preferred products are not right for the enrollee. Based on 
this information, we decided that Medicare rules for coverage of diabetic supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Smartview strips (A4253).
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 would be in your best interest to go to 
an LTACH. The Plan denied your request. The Plan says your records do not show that you need continued 
treatments that can only be given in hospital setting or that your condition will probably require an average 25-
day length of stay in the LTACH. 
 
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 that all medically necessary care is being provided in the current acute care 
setting. There are no services available at the LTACH that you require that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and 
condition and able to be furnished safely and effectively only on an inpatient basis. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says your records do not 
show that you need skilled nursing services daily and do not have to be in a nursing home to receive your level 
of assistance. The services you require with bathing and grooming can safely be received at a different setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on  
October 25, 2022. 
 
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 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on October 25, 2022.