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

 
We decided that the Plan does not have to pre-approve occipital nerve injections. 
 
You asked the Plan to pre-approve the occipital nerve injections. You say that you would like reconsideration 
because the requested service is medically necessary. The Plan denied your request. The Plan says this service 
is considered 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 occipital nerve injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found occipital nerve block therapy is considered investigational for the treatment 
of occipital neuralgia and headache syndromes including, but not limited to, chronic migraine, chronic daily 
headache, cervicogenic and cluster headache. 
 
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 occipital nerve injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve occipital nerve injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab and x-ray reading provided on October 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the lab and x-ray reading. You say that you would like the claim to be reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab and x-ray reading provided on October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99350) rendered by the out-of-network (OON) provider on December 14, 2021. 
 
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 the service was rendered by an out of network 
provider, without prior authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the home visit for the evaluation and management of an established patient (99350) 
rendered by the out-of-network (OON) provider on December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Euflexxa before it will approve Synvisc. 
 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 Synvisc. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Euflexxa. The documentation does not support that 
this drug would likely be less effective and/or 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and teeth 
extractions (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and teeth extractions. You say that you 
were referred to an oral surgeon by your dentist because he cannot provide the services needed. You also say 
that you are in extreme pain, cannot chew food or touch the top or bottom of your teeth and currently eating 
soft foods. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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. The Plan covers a 
comprehensive oral evaluation and teeth extractions when the services are performed by a participating general 
dentist.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and teeth extractions have not been met. Specifically, dental 
services must be performed by a participating general dentist. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and teeth extractions (D7210) to be provided by 
an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy care 
and requires close daily oversight by a physician in an inpatient setting. You say that she will receive the 
appropriate level of care in the acute rehabilitation setting and a delay in care will have a detrimental effect on 
her safety and ability to recover to the fullest extent. The Plan denied your request. The Plan says care can 
safely be received in another setting. 
 
  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. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies at an intensive 
rehabilitation therapy program. Although the member continues to have a need for skilled therapy, the 
documentation doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility. The member can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing (81529) provided on 
November 22, 2021. 
 
You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that you would like reconsideration 
because this testing was medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet LCD or medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the DecisionDx testing may be covered when the 
criteria listed in the Medicare rules section of this letter 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 pay for the DecisionDx-Melanoma testing. Our 
reviewer says that the enrollee does not meet LCD criteria for coverage of this testing. Our physician reviewer 
found the documentation does not support that the enrollee has Stage T1b and above or has T1a with 
documented concern about adequacy of microstaging, is undergoing workup or being evaluated for treatment 
and has a presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or 
other information is >5%. 
 
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 DecisionDx-Melanoma testing have not been met. Additionally, the rules 
state that this testing must be billed with CPT code 81599. Therefore, we decided that the Plan does not have to 
pay for the DecisionDx-Melanoma testing (81529) provided on November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the computed tomographic angiography, of 
the heart, coronary arteries, and bypass grafts (75574) provided on November 22, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service provided as you had not met the annual deductible. 
 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a network 
physicians office or at a network free-standing facility. The Plan benefit states that your annual deductible is 
$750. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered 
medical services.   
 
You have been asked to pay $363.65 for the Medicare-covered radiological diagnostic service provided as you 
had not previously met the annual deductible. This is the Plans allowed amount for this service. 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 adjust the cost share for the computed tomographic angiography, of the heart, coronary 
arteries, and bypass grafts (75574) provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bilateral L1-2, L2-3 rhizotomy under fluoroscopic guidance.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that the need was not met because there is insufficient evidence in the published medical
literature to determine the safety and efficacy of these emerging alternative modalities or approaches compared
to thermal radiofrequency denervation for the treatment of spinal pain.
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 pre-approve the services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee underwent two sets of diagnostic medial branch blocks, and achieved greater than 80% pain
relief each time. Surgical intervention is a well-established approach to facet pain management. It 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 services have been met. Therefore, we decided that the Plan has to preapprove
bilateral L1-2, L2-3 rhizotomy under fluoroscopic guidance.
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 bone replacement graft (D7953) provided on November 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were told that your segmented tooth would 
be covered under your dental rider. The Plan denied your request. The Plan says grafting procedures are 
excluded from coverage. 
 
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 bone replacement graft is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve a partial upper denture. You say that when you received the service in 
October 2020, you were not satisfied because the partial did not fit correctly. You are having issues eating, 
causing pain and loss of weight. The Plan denied your request. The Plan says your benefit has been exhausted 
for the 2022 plan year. 
 
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. The Plan covers a partial 
upper denture once every 5 years.  
 
We looked at the file and Medicare rules. The records show that you received a partial upper denture on 
October 30, 2020; therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a partial upper denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts (D7953 x 2) provided from 
September 16, 2020, to October 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that the bone replacement grafts (D7953 x 2) 
provided from September 16, 2020, to October 28, 2021. The Plan denied your request. The Plan says routine 
dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts 
(D7953 x 2) provided from September 16, 2020, to October 28, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the patient's needs can be met at a lower 
level of care. 
 
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. Our physician reviewer found the patient does not require the intensity of services provided at an IRF.  Specifically, 
the patient is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  The patient's care needs can be met 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 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 power seat elevation system (E2300), a power 
wheelchair expandable controller (E2377), a harness (E2313), a power wheelchair electrical connection 
(E2311), a transit package (K0108), a control with 5 or more toggle switches (K0108), a remote joystick 
replacement (E2374), an armrest (E0994), power wheelchair non-standard seat frames (E2340 and E2342), a 
special wheelchair seat height (E1296), and a battery charger (E2366). 
 
You asked the Plan to pre-approve codes E2300, E2377, E2313, E2311, K0108, E2374, E0994, E2340, E2342, 
E1296, and E2366. You say that the items which remain in dispute are medically necessary and supported by 
the records provided. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage of the items which remain in dispute. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that items and services that are not medically necessary are not covered. 
The rules say that if DME serves the same purpose as equipment already available to an enrollee, it is not 
considered reasonable and 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 codes E2300, E2377, E2313, E2311, 
K0108, E2374, E0994, E2340, E2342, E1296, and E2366. Our reviewer says that the criteria for coverage have 
not been met. Our physician reviewer found a power seat elevation system (E2300), a harness (E2313), the 
transit package (K0108) is not primarily medical in nature, are available to the general public, and would be 
helpful even to those who are not sick or injured. Our physician reviewer found that the documentation does 
not support that the power wheelchair expandable controller (E2377), the power wheelchair electrical 
connection (E2311) and the remote joystick replacement (E2374) are medically necessary to control power 
options through a joystick. The power options can be controlled with the joystick and their own switches. Our 
physician reviewer found that the armrest (E0994), the power wheelchair seat frames (E2340 and E2342), the 
seat height E1296), and the battery charger (E2366) are all included with the approved chair.  
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300), a 
power wheelchair expandable controller (E2377), a harness (E2313), a power wheelchair electrical connection 
(E2311), a transit package (K0108), a control with 5 or more toggle switches (K0108), a remote joystick 
replacement (E2374), an armrest (E0994), power wheelchair non-standard seat frames (E2340 and E2342), a 
special wheelchair seat height (E1296), and a battery charger (E2366).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 8, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that a plan representative advised that 2 
regular cleanings and 1 deep cleaning are covered per year. You also say that you feel you were given 
completely misleading information by the plan. The Plan denied your request. The Plan says limited oral 
evaluation is not listed as a covered service. 
 
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 limited oral evaluation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and removal of residual tooth roots (D7250) provided on October 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised the services would be 
covered. You also say that you were not aware that it was not covered. The Plan denied your request. The Plan 
says the annual maximum benefit of $500 has been exhausted. 
 
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 annual maximum benefit of $500 
has been exhausted. The record shows that the Plan paid $55 for services received on April 1, 2021, $104 for 
services received on May 25, 2021, and $341 for services received on November 18, 2021. $55 + $104 + $341 
= $500. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), 
periapical x-ray (D0220), and removal of residual tooth roots (D7250) provided on October 28, 2021.