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

 
We decided that the Plan does not have to pre-approve a third level cervical radio-frequency ablation (64633, 
64634). 
 
You asked the Plan to pre-approve a third level cervical radio-frequency ablation. You say that the enrollee has 
a history of chronic neck and low back pain. The requested RFA is medically necessary due to the level of pain 
the enrollee reports. The Plan denied your request. The Plan says the provided documentation does not show a 
treatment plan that the requested procedure will be done at no more than two levels of the spine and there was 
at least 50% improvement of pain and/or function for at least six months after the previous procedure. 
 
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 cervical radio-frequency ablation. Our 
reviewer says that the requested items/services are not considered medically necessary in this case. Our 
physician reviewer found the enrollee has chronic neck pain. She has tried heat/ ice and medication trials. She 
had a cervical ESI which gave her 35% pain relief. On March 9, 2022, she had left C2-C4 RFA which gave her 
70% pain relief. On May 6, 2022, she had right C2, C3, C4 and C5, which gave her 60% pain relief. There is a 
utilization limit of two levels bilaterally RFA. The third level request exceeds this limit. Therefore, two levels 
are considered medically reasonable and necessary. The third level is deemed not 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 a cervical radio-frequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a third level cervical radio-frequency ablation (64633, 64634).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 06, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization should be obtained 
by hospital staff. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on October 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 an extraction (D7210) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on June 24, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider, without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in-network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
when purchased from an in-network provider. However, the hearing aids in this case were purchased from an 
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the 
hearing aids purchased on June 24, 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 an IRF admission is the only chance the enrollee 
may have at approval with an opportunity to regain function. The Plan denied your request. The Plan says 
admission to an IRF is 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 that 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pegfilgrastim-jmdb (Q5108) provided on November 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pegfilgrastim-jmdb. You say that the treatment was medically necessary, 
reasonable, and necessary for the treatment of the enrollee's condition. The Plan denied your request. The Plan 
says prior authorization was not obtained prior to rendering services.  
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 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 the pegfilgrastim-jmdb (Q5108) provided on 
November 3, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens, the ultraviolet lens, the anti-reflective 
coating per lens, and the tint provided on January 14, 2023. 
 
You asked the Plan to pay for the polycarbonate lens, the ultraviolet lens, the anti-reflective coating per lens, 
and the tint. You say that you do not believe you should be liable for any additional out-of-pocket expenses 
because you would not have proceeded with the order if the cost was beyond the amount, you have already 
paid. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 covers these services when not covered. 
 
We looked at the file and the Plan's rules. Specifically, the enhanced services are not covered benefits. Based 
on this information, we decided that the Plan's rules for coverage of the polycarbonate lens, the ultraviolet lens, 
the anti-reflective coating per lens, and the tint have not been met. Therefore, we decided that the Plan does not 
have to pay for the polycarbonate lens, the ultraviolet lens, the anti-reflective coating per lens, and the tint 
provided on January 14, 2023.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on December 26, 2022.

You asked the Plan to pay for the office visit. You say that the services were provided and billed correctly under the supervision of the physician. The Plan denied your request. The Plan says that the claim needs to be re-billed under the supervising physician as per CMS rules regarding Physician Assistant/Nurse Practitioner coverage.

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. The Plan has not provided a valid Medicare rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an office visit provided on December 26, 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: 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 enrollee does not meet the requirements for an IRF 
admission. 
 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the routine eye exam and the fundus photography 
provided on November 7, 2022. 
 
You asked the Plan to pay more for the routine eye exam and the fundus photography. You say that you have a 
history of detached retina and was overdue for a yearly checkup. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
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 covers these services once per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a routine eye exam on May 3, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
routine eye exam have not been met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 which applies to the fundus photography.  
 
The item or service you asked the Plan to pay for falls within the vision care benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to 
the fundus photography. The record shows $33.83 was applied to your deductible. This cost sharing is a 
contractual obligation that had not been met at the time the fundus photography was received on November 7, 
2022.   
 
Therefore, we decided that the Plan does not have to pay more for the routine eye exam and the fundus 
photography provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94760 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 94760. The Plan denied your request. The Plan says procedure 
code 94760 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 94760 has a status indicator of T on the Physician Fee Schedule and was billed 
with other services that are payable. This means that procedure code 94760 is considered bundled and not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
94760 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 94760 
billed for date of service October 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopy (EGD) provided on August 29, 2022. 
 
You asked the Plan to pay for an endoscopy (EGD). You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an endoscopy (EGD) 
provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 11, 2022, to November 17, 
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 May 11, 2022, to November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial ankle with swing phase active dorsiflexion 
feature and flex-walk system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic additions are covered when specific 
criteria 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the submitted records do not 
support that the enrollee is a K3 ambulator or that his functional activities require the requested K3 level items. 
The requested items exceed the enrollee's needs and are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a multiaxial ankle with swing phase active dorsiflexion feature and flex-walk system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on 
December 7, 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 your benefit for the requested item or service 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 requested item or service was exhausted on date of service December 28, 2020. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that the services should be reimbursed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bilateral (right and left side) T11-L2 Medial Branch 
Block (MBB) (64490, 64491). 
 
You asked the Plan to pre-approve a MBB. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the criteria 
listed 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 a MBB. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the cause of the member's pain is unclear. 
 
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 MBB have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Bilateral (right and left side) T11-L2 Medial Branch Block (MBB) (64490, 64491).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer System Implantable Pulse Generator 
(IPG) (device/technique used to deliver Cardiac Contractility Modulation (CCM) therapy). 
 
You asked the Plan to pre-approve an IPG. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this service is considered experimental. 
 
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 IPG. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this service is considered experimental. 
 
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 IPG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an Optimizer System Implantable Pulse Generator (IPG) (device/technique used to deliver 
Cardiac Contractility Modulation (CCM) therapy).