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

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve facet joint RFA services. You say that this is medically necessary for the 
enrollee's pain. The Plan denied your request. The Plan says the requested RFA services would exceed the 
benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months 
 
We looked at the file and Medicare rules. In this case, when the request for RFA services was made 12 months 
had not elapsed since the previous RFA services. Based on this information, we decided that Medicare rules for 
coverage of facet joint RFA services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve facet joint radiofrequency ablation (RFA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 an epidural injection provided on 
November 22, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 18, 2021 by 
a Medicare opt out provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you are eligible for up to $1,000 in dental 
reimbursements for the 2021 plan year. You also say that you do not have to see an in-network provider to be 
reimbursed. The Plan denied your request. The Plan says this service was rendered by a provider who chose not 
to receive Medicare funds. The Plan also says that services performed by an opt out provider cannot be paid by 
the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis (D1110) provided on November 18, 2021 by a Medicare opt out 
provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more therapy The Plan denied your 
request. The Plan says that SNF care is not reasonable and necessary for the treatment of the enrollee's 
condition. 
 
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 
criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is noted to have 
an acute decline in function due to a new stroke. While the enrollee did not fully participate in her physical 
therapy evaluation on the day of hospitalization, the enrollee clearly participated in her occupational therapy 
evaluation the next day. Daily skilled services are required to establish a maintenance program and/or to 
prevent deterioration of the enrollees condition. Given her age, her chronic need for an ankle foot orthosis 
(AFO), recent need for thoracolumbosacral orthosis (TLSO) and new stroke, the enrollees care needs, as a 
practical matter, cannot be provided at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the enrollee has complex carotid issues. 
You say that the enrollee has greater than 99% stenosis in the right internal carotid artery but is asymptomatic. 
You say that the enrollee also has 50-69% stenosis in the left internal carotid artery, but that is the one that is 
symptomatic with a recent stroke. The Plan denied your request. The Plan says the request 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 placement of an ILR. Our reviewer says 
that placement of an ILR is not considered medically reasonable and necessary in this case. Our physician 
reviewer found, while the enrollee has a history of atrial fibrillation and carotid artery disease, there is no 
documentation provided to suggest a history of unexplained syncope or any other apparent indication for an 
ILR. There is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollee's clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 1, 2021. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the Plan's decision to deny 
payment. The Plan denied your request. The Plan says there is insufficient documentation to support the 
medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the records provide are 
not dated and not signed by the physician. The Plan made multiple attempts to obtain the clinical records to 
support the medical necessity of the services. Therefore, we decided that the Plan does not have to pay for 
injection, of diagnostic or therapeutic substances (anesthetic, antispasmodic, opioid, steroid, other solution), not 
including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, 
cervical or thoracic (62320) provided November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl for an intrathecal pump. 
 
You asked the Plan to pre-approve the Fentanyl. You say that Fentanyl is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Fentanyl. Our reviewer says that 
Fentanyl is not medically necessary. Our physician reviewer found Fentanyl is not an FDA approved 
medication for intrathecal use in pain pumps. While it is commonly used, the FDA has issued warnings on off-
label use. It's use is not supported by one of the major drug compendia. 
 
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 Fentanyl have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fentanyl for an intrathecal pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft. You say that the enrollee requires this service. 
The Plan denied your request. The Plan says this service is not covered under the enrollee's benefits. 
 
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 
bone replacement graft for ridge preservation - per site (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on August 19, 
2021. 
 
You asked the Plan to pay for electric stimulation therapy (97014). You say that the claim denied for bundling 
yet all other claims billed the same way have been paid. The Plan denied your request. The Plan says CPT 
codes 97110, 97140 and 97112 have been overturned. The Plan also says CPT code 97014 remains denied as 
the code is not valid for Medicare billing purposes. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of electric stimulation therapy (97014) have not been met. Therefore, we decided that the Plan does 
not have to pay for electric stimulation therapy (97014) provided on August 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve HHA services. The Plan denied your request. The Plan says you do not meet 
the Medicare criteria for approval of HHA services set forth by Medicare. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 HHA services. Our reviewer says that 
HHA services are not shown to be medically necessary or reasonable to assist in the treatment of illness or 
injury. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer found 
that you do not have documented skilled therapy needs. Our physician reviewer also found that your needs 
appear to be custodial, daily and long-term. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services (G0156).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that continued PT is recommended to 
emphasize the enrollee's post-operation range of motion and functional mobility. The Plan denied your request. 
The Plan says the enrollee has not shown significant improvement in a reasonable period of time. 
 
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 PT 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 documentation does not reveal that the patient requires the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer also found 
that the requested services are not part of a maintenance program, and 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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office or other outpatient visit for the evaluation and 
management of a new patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making (99204) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology consultation and treatment. You say that the enrollee 
requires consultation with an oculoplastic specialist. The Plan denied your request. The Plan says this service 
can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office or other outpatient visit for the evaluation and management of a new patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making (99204) to be 
provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you recommend continued therapy to 
resolve the enrollee's issues. The Plan denied your request. The Plan says the requested service does not meet 
medical necessity criteria. 
 
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 PT 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 PT is an accepted treatment for hamstring injury/strain in the 
literature, however there is no documentation to suggest the patient would benefit from additional skilled 
therapy sessions. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 14 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G. 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary as recognized by medical communities and 
key opinion leaders in rehabilitation. The Plan denied your request. The Plan says there is not enough medical 
evidence that shows the MyoPro is reasonable and necessary to improve the function of the enrollee's right 
arm. 
 
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 2 Motion G. Our reviewer 
says that there is no documentation that the MyoPro 2 Motion G device at issue in this case meets Medicare 
criteria for medically reasonable and necessary. Our physician reviewer found current clinical guidelines 
designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb 
exercise therapies" with unproven benefit in the home environment. 
 
 
 
 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 2 Motion G have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro 2 Motion G.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 29, 2021. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the Plan's decision to deny 
payment. The Plan denied your request. The Plan says there is insufficient documentation to support the 
medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the records provided are 
undated and unsigned. The Plan made multiple attempts to obtain clinical records without success. Therefore, 
we decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you do not have 
transportation to your medical appointments. The Plan denied your request. The Plan says that you have 
exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per 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 of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) and resin-
based composite (D2332) provided on December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray and resin-based composite. You say that 
you cannot afford to pay for these services. The Plan denied your request. The Plan says the treating provider is 
OON and an authorization to utilize an OON provider was not obtained. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
additional intraoral periapical x-ray (D0230) and resin-based composite (D2332) provided on December 9, 
2021 by an out-of-network (OON) provider.