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

 
We decided that the Plan does not have to pre-approve breast augmentation surgery with breast implant, 
removal of the previous implant, and feminization of bilateral areola. 
 
You asked the Plan to pre-approve breast augmentation surgery with breast implant, removal of the previous 
implant, and feminization of bilateral areola. You say that the requested breast augmentation surgery with 
breast implant, removal of the previous implant, and feminization of bilateral areola is medically necessary. 
The Plan denied your request. The Plan says the requested breast augmentation surgery with breast implant, 
removal of the previous implant, and feminization of bilateral areola 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 breast augmentation surgery with breast 
implant, removal of the previous implant, and feminization of bilateral areola. Our reviewer says that the 
requested breast augmentation surgery with breast implant, removal of the previous implant, and feminization 
of bilateral areola is not medically necessary. Our physician reviewer found the enrollee is a transgender (male 
to female) individual who is experiencing gender dysphoria related to the masculine areola size. The enrollee underwent breast augmentation in 2016. The enrollee expresses a desire for revision. The plastic surgery note 
dated February 1, 2022, documents that the enrollee "is not happy with the size and wishes for more medial 
fullness." Physical examination of the breasts documents no masses, peau d'orange, lymphadenopathy, or 
ptosis. On May 17, 2022, it is documented that the enrollee experiences dysphoria related to her masculine 
areola size. The documentation does not support that the requested breast augmentation surgery with breast 
implant, removal of the previous implant, and feminization of bilateral areola is medically reasonable and 
necessary for the enrollee's unique clinical scenario. Medicare says that surgery to re-shape normal body parts 
to improve their appearance is not covered. You have not had an injury or surgery to your breast area that has 
caused malformed breasts. The surgery you are asking for is considered cosmetic. Cosmetic surgery is not 
covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast augmentation surgery with breast implant, removal of the previous 
implant, and feminization of bilateral areola have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast augmentation surgery with breast implant, removal of the previous implant, and 
feminization of bilateral areola.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary for surgical planning. The 
Plan denied your request. The Plan says that the records do not show one of the indicated types of tremors. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that this enrollee has 
essential tremor, and the MRI which has been ordered is considered a pre-operative exam necessary for 
surgical planning. As such, the scan is medically necessary, and should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the bilateral sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the bilateral sacroiliac joint. You say that the 
requested radiofrequency ablation of the bilateral sacroiliac joint is medically necessary. The Plan denied your 
request. The Plan says the requested radiofrequency ablation of the bilateral sacroiliac joint 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 radiofrequency ablation of the bilateral 
sacroiliac joint. Our reviewer says that the requested radiofrequency ablation of the bilateral sacroiliac joint is 
not medically necessary. Our physician reviewer found the enrollee is with a history of chronic low back pain 
due to lumbar degenerative disc disease and bilateral sacroiliac joint (SIJ) dysfunction. Prior SIJ injections and 
plasma rich protein (PRP) injections did not provide relief of pain. He has tried NSAIDs, massage, heat, and 
muscle relaxants which have provided some relief. He started acupuncture, but only 3 sessions with no 
significant changes yet. He had a medial branch block (MBB) done on July 18, 2022, with 80-90% relief. The 
provider requested a bilateral sacroiliac joint (SIJ) radiofrequency ablation (RFA).  
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 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 radiofrequency ablation of the bilateral sacroiliac joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the bilateral 
sacroiliac joint.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no indication your pain and/or other symptoms are severe 
enough to greatly impact quality of life or function. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation provided indicating that you have had pain duration of at least four (4) weeks, with the inability 
to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of 
noninvasive conservative care or acute herpes zoster refractory to conservative management where a four (4) 
week wait is not required. Our physician reviewer found that your condition does not meet criteria for coverage 
of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 70551. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70551 is bundled into payment for code 70552. 
 
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 70551 is a column II code to column I code 70552. 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 procedure code 70551 billed for date of service May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and the 
panoramic radiographic image (D0330) provided on February 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service August 23, 2021. Specifically, 
the Plan provides coverage of one panoramic radiographic image and one comprehensive oral examination 
every three years. You previously received these services on August 23, 2021, which were paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for these services.  Therefore, we decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and 
the panoramic radiographic image (D0330) provided on February 12, 2022.
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 admission is medically necessary. The Plan 
denied your request. The Plan says there is no indication the enrollee meets standard criteria for admission to 
an inpatient rehabilitation unit for care. Daily therapy can be supplied at a lower level of care if desired, 
whether given in a skilled nursing facility or at home. 
 
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 a history of an ankle fracture managed nonoperatively and is 
living at home with ongoing weakness. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
December 27, 2020. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says a 
corrected claim must be received within one year (12 months) from the processed date of the original claim 
submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until April 14, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
December 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on January 24, 2022. 
 
You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says infrared 
therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on January 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental code D2954 provided on April 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental code D2954 provided on April 14, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
November 22, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were not related to the 
enrollee's hospice election. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 25, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis (L3960) provided 
May 17, 2022. 
 
You asked the Plan to pay for the orthosis. You say that please see the attached medical records 
 The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the right shoulder orthosis at issue in this case meets all Medicare criteria for medically reasonable and necessary. The provided 
medical visit notes from April 8, 2022 and May 2, 2022 document a diagnosis of right shoulder pain but the 
visit notes do not document any detailed history of the right shoulder pain. The medical visit notes report an 
order for x-rays of the shoulder as well as an orthopedic referral and treatment with prednisone, but records do 
not mention a need for or a prescription for a right shoulder orthosis. Of note, x-rays of the left shoulder are 
reported to show degenerative changes. No right shoulder x-ray reports are provided. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the shoulder-elbow-wrist-hand orthosis (L3960) provided May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services. You say that you have seen this provider in the past. 
The Plan denied your request. The Plan says that according to Medicare guidelines, an out of network provider 
may be needed if the Plan does not have a doctor who can do the services that are needed to treat your problem. 
This request can be safely given by an in-network provider; therefore, the requested service cannot be covered 
under Medicare or your health Plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion. 
 
You asked the Plan to pre-approve a lumbar spine fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 lumbar spine fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous process devices are 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 a lumbar spine fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar spine fusion.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 7, 2021, to December 28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is not sufficient documentation in this case to support the administration of parenteral 
and/or intravenous feeding while not a resident during the reference period. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that sodium chloride and potassium 
chloride were administered in the ED on 11/30/21. Cefazolin and Hydralazine were administered. On 12/1/21 a 
right total hip arthroplasty was performed. On an assessment date of 12/8/21 it is noted that the enrollee was 
independent with eating. The documentation does not support parenteral and/or intravenous (IV) feeding 
during the period in question. 
 
 We looked at this coder'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 pay for skilled nursing facility (SNF) services provided to the enrollee from December 7, 2021, to 
December 28, 2021.