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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that this service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the records do not show the enrollee has 
pain severe enough to greatly impact the quality of life or function. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections should be performed 
in conjunction with conservative treatments and patients should be part of an active rehabilitation program, 
home exercise program or functional restoration program. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support the fact that the 
enrollee has completed conservative treatment and no evidence they are currently part of a of an active 
rehabilitation program, home exercise program or functional restoration program. Based on this information, 
we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says the documentation 
does not support that the enrollee meets any of the requirements for approval. 
 
 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 Lucentis. Our reviewer says that 
Lucentis is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our 
reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99291) provided on February 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99291 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (99291) provided on February 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 11. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says core build up is covered once per tooth every 5 plan years. The Plan also says that the 
frequency limit has been exceeded. 
 
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 and core build up is listed as covered, 
the frequency limit of once per tooth every 5 plan years has been exceeded. The record shows that the Plan paid 
for core build up for tooth # 11 that you received on October 13, 2020. Therefore, we decided that the Plan 
does not have to pre-approve core build up (D2950) for tooth # 11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on May 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the order/lab requisition 
must include what laboratory test was ordered/requested in order to validate the not elsewhere specified code 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. In this case, the validity testing is being utilized for drug testing. This 
is not separately payable. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the specimen validity testing 
provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature (L5968) All lower extremity prostheses, flex-walk system (L5981). 
 
You asked the Plan to pre-approve the K3 foot. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says a K3 foot exceeds the enrollee's needs 
and does not meet Medicare criteria as reasonable and 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 K3 foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not describe the patient at a K3 level of function to justify 
utilization of a K3 foot prosthesis at this time. There was also no report of the patient being exposed to outdoor 
harsh environment on a regular basis to justify this request. Therefore, the records do not meet Medicare 
coverage criteria for the above request. 
 
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 K3 foot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968) All lower extremity prostheses, flex-walk system (L5981).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the heart 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for asymptomatic patients. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that according to the 
physician, the enrollee is asymptomatic from a cardiovascular standpoint. Numerous studies have demonstrated 
that coronary artery calcium (CAC) scoring using ultrafast cardiac CT adds predictive value in assessing risk of 
coronary heart disease (CHD). Overall, there is insufficient support in the peer-reviewed literature 
demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium 
in guiding optimal management of this enrollee. As such, CT imaging of the heart without contrast material 
with quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation 
and management of this enrollee's medical condition. 
 
 
 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography angiography (CTA) of the heart for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610) and deep 
sedation/general anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the therapeutic parenteral drug and deep sedation/general anesthesia. You 
say that you need the sedation for the extractions to be done properly. The Plan denied your request. The Plan 
says these services are not covered under your benefit plan. 
 
  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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic parenteral drug (D9610) and deep sedation/general anesthesia (D9222 and D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your medical conditions are not yet stabilized enough to where you can 
tolerate and participate in the IRF level of therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for left sided weakness, 
bacteremia, right upper extremity phlebitis and NSTEMI. Your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF care. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your medical conditions are not yet stabilized enough to where you can 
tolerate and participate in the IRF level of therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for coronary stent for 
atherosclerosis and was discharged home. You have had weakness and frequent falls since discharge. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0670).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed a basic pump. 
 
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 there is no documentation that the enrollee has lymphedema extending onto the chest, trunk or 
abdomen. Based on the medical records provided, there is no documentation that the enrollee has failed an 
adequate trial of a standard pump to verify that the enrollee has the unique characteristics that would indicate 
the segmented 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, E0670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the therapeutic parenteral drugs. You say that you need this service to be 
covered because you have extreme anxiety about having dental work done. 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 Plans 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 
therapeutic parenteral drugs (D9612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy and implantation of spinal 
neurostimulator. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been a successful temporary neurostimulator trial as required by Medicare. 
 
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 criteria is not met, and there is no trial of a stimulator documented. 
 
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 laminectomy and implantation of spinal neurostimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia (D9222 and D9223) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve general anesthesia. You say that you are having teeth pulled and you need 
the anesthesia. The Plan denied your request. The Plan says the requested dental services are 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
general anesthesia (D9222 and D9223) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intrasseous basivertebral nerve 
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 this is considered experimental and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure(destruction of the basivertebral nerve) is experimental. More research is needed. 
 
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 thermal destruction of intrasseous basivertebral nerve for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endosteal implants (D6010 x 15), prefabricated 
abutments (D6056 x 15), and implant supported crowns (D6065 x 15). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee does not tolerate dentures. You 
also say that the enrollee cannot chew food well. The Plan denied your request. The Plan says dental implants 
and all associated services are not covered. 
 
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 requested implant and associated 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the endosteal implants (D6010 x 15), prefabricated abutments (D6056 x 15), and implant 
supported crowns (D6065 x 15).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral lateral nerve branch 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 this is considered experimental and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Studies completed say that this procedure does not improve outcomes compared to standard 
treatment of sacroiliac joint (SIJ) pain.  Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral lateral nerve branch ablation for the enrollee.