Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 radiofrequency ablation. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has chronic low back pain and sacroiliitis. The enrollee has had 
diagnostic lateral branch blocks. The requested procedure is considered experimental/ investigational because 
of the wide variation in efficacy reported in the literature. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the lateral sacral branches.
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 the services will provide the enrollee with 
comprehensive wound care and direct physician supervision. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting such as home with home health services, 
or home with outpatient services. 
 
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 enrollee has no rehab nursing needs. The documents do not support medical 
necessity for admission to an IRF. The enrollee has no medical complexity currently with no acute rehab 
nursing needs for an IRF admission. The enrollee is functionally doing well. The enrollee would benefit from 
physical and occupational therapy, their rehab needs can be safely provided in an alternate and low intensity 
setting such as in-home with services or continued in the skilled nursing facility. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
became ill after being released from the hospital on February 4, 2022. You also say that your primary care 
physician advised you to seek medical treatment so an ambulance was called. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, platelet rich plasma, any site, including 
image guidance, harvesting and preparation when performed (0232T). 
 
You asked the Plan to pre-approve injections. You say that you have submitted medical records to support the 
reconsideration of the denied platelet rich plasma injections. The Plan denied your request. The Plan says this is 
not an approved indication per the NCD and there is insufficient evidence in the peer reviewed literature to 
support platelet rich plasma for osteoarthritis or an improved health outcome. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found more uniformly positive results have been observed by various studies for PRP in OA 
(osteoarthritis) knee in comparison to hyaluronic acid, other intra-articular injections, and placebo than in other 
musculoskeletal tissue. Thus, further research is required to investigate how leukocyte inclusion, activation, 
and platelet concentration affect therapeutic efficacy. For knee OA management, these concerns must be 
addressed before this promising treatment can be widely implemented. This benefit increases over time, being 
not significant at earlier follow-ups but becoming clinically significant after 6 to 12 months. Although 
substantial, the improvement remains partial and supported by low level of evidence. This finding urges further 
research to confirm benefits and identify the best formulation and indications for PRP injections in knee OA 
(osteoarthritis). However, there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Additionally, there is limited 
documentation supporting she has failed the recent physical therapy sessions. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested injection in this clinical setting. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested platelet-rich plasma injection, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection, platelet rich plasma, any site, including image guidance, harvesting and preparation 
when performed (0232T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 01, 2022, billed 
with procedure codes 99204, 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. The claim was billed with place of service code 11 for an office visit 
however, the records indicate that the services were rendered in a nursing facility setting. There is a more 
appropriate POS code for this claim. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for medical 
services provided on November 01, 2022, billed with procedure codes 99204, 74230, 72040, 70100, 70310, 
and 74240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on November 30, 2022.
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 the enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollee's records do not show the need to 
be seen by a rehabilitation doctor at least 3 times a week or an intensive team for your care, services needed 
can be provided safely in other settings, a skilled nursing facility, home with home health services or home 
with outpatient 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. Our 
physician reviewer found the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is a covered benefit. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not collect medical records from the provider who 
ordered the requested CGM. There was no documentation submitted to show the network status of the provider 
and if they are a participating provider then they are considered agents of the Plan. Without this necessary 
documentation we are unable to make a determination as to whether the enrollee has met the criteria for 
coverage of a CGM. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor 
(CGM).  
 
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 trifocal eyeglass lenses (V2303) and anti-reflective 
coatings (V2750) provided on November 10, 2022. 
 
You asked the Plan to pay for the trifocal eyeglass lenses and anti-reflective coatings. You say that both the bill 
and the Plan's notice of denial make it clear that no frames were purchased. You also say that you do not wear 
trifocals, but wear bifocals. The Plan denied your request. The Plan says your optical frame allowance has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $150 allowance every 24 months that you can use to pay for eyewear.  
We looked at the file and the Plan's rules. Although the Plan's denial says the optical allowance was applied for 
the frames, the record shows that you only received lenses, which is what your eyewear allowance was applied 
toward. Specifically, the record shows that the Plan applied the full $150 allowance toward this purchase, and 
your eyewear allowance has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the trifocal eyeglass lenses and anti-reflective coatings have not been met. Therefore, we decided 
that the Plan does not have to pay for the trifocal eyeglass lenses (V2303) and anti-reflective coatings (V2750) 
provided on November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services are not medically necessary. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007). 
 
You asked the Plan to pre-approve an extra heavy-duty wheelchair. You say that the requested wheelchair is 
medically necessary. The Plan denied your request. The Plan says the request for this extra heavy-duty 
wheelchair does not meet medical necessity criteria. 
 
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 an extra heavy-duty wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a normal gait and normal neurological exam. The record does not 
support you have a functional deficit which requires a manual wheelchair to allow you to complete your ADLs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an extra heavy-duty wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair for a power wheelchair. 
 
You asked the Plan to pre-approve the repair for a power wheelchair. You say that the service is medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment 
(DME) in a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the repair for a power wheelchair is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve the repair for a power wheelchair.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on October 27, 2022. 
 
You asked the Plan to pay for the testing services. You say that the results inform treatment decisions. The Plan 
denied your request. The Plan says that services must include an identifier as additional claim information. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plans denial decision was based on the Palmetto GBA Manual. This is 
not a Medicare-approved citation for billing guidelines. No other valid Medicare rule was presented by the 
Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request.  Therefore, we decided that the Plan has to pay for the lab testing services 
provided on October 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
You asked the Plan to pre-approve SSBCI. You say that you really need this approved to help with your 
utilities. The Plan denied your request. The Plan says the Plan requires supporting medical records from your 
provider; however, none were obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. Specifically, no 
supporting records were submitted by your treating provider. The Plan made several attempts to obtain medical 
records, but none were provided. Without medical records, we cannot determine whether you meet the 
Medicare criteria to qualify for SSBCI. Therefore, we decided that the Plan does not have to pre-approve 
special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injections (0232T). 
 
You asked the Plan to pre-approve PRP injections. You say that these injections were recommended by your 
specialist. You also say that this will help you instead of having surgery. The Plan denied your request. The 
Plan says the requested injections are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PRP injections and/or applications as a means of 
managing musculoskeletal injuries and/or joint conditions is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PRP injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve platelet rich plasma (PRP) injections (0232T).