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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA services. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says according to Medicare rules, radiofrequency ablation to 
sacroiliac joint not covered. 
 
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 RFA services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has been diagnosed with bilateral sacroiliitis. In this case, the requested 
procedure is considered an experimental/investigational procedure because of the wide variation in efficacy 
reported in the literature. Therefore, the request is considered 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the 
sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmologist visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmologist visit. You say that you would like a second opinion and 
the in-network provider is too far. The Plan denied your request. The Plan says the requested provider is an 
OON provider and there are 2 in-network providers available that are the same distance as the requested OON 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ophthalmologist visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has pain and will benefit from this 
procedure. The Plan denied your request. The Plan says that this service is considered experimental and 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's 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 the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested Vertiflex procedure is considered 
experimental/investigational for the enrollee's condition. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage will 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277) for 
the enrollee. 
 You asked the Plan to pre-approve the mattress. You say that the enrollee is bed-ridden and needs to be moved 
every two hours. The Plan denied your request. The Plan says the criteria is not 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 the mattress. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a powered pressure reducing air mattress (E0277) is not medically necessary as the documentation 
does not reveal that the patient has multiple stage II pressure ulcers located on the trunk or pelvis, which have 
been treated in a comprehensive program. The documentation does not reveal large or multiple stage 3 or 4 
pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or 
pelvis within the past 60 days. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure reducing air mattress (E0277) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says that rules for IRF care have not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found there are complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for LTACH 
services. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
acute setting. The LTACH would add no additional services. With additional time in the current setting, 
clinical stability can be ensured such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable but with a poor prognosis. Additional 
acute care services are required that can safely be administered at the current facility until more appropriate for 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that you were told these services would be covered. The Plan denied your request. The Plan says the services at 
issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and an abutment supported crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the service can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has already failed at a lower 
level of care. The Plan denied your request. The Plan says it is not medically safe for the enrollee to go to an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee presented to the acute hospital with septic shock, pneumonia, urinary tract 
infection and acute kidney injury. The short-term acute care hospital can provide for all the enrollees present 
inpatient care needs, and she is receiving an appropriate level of care in the present setting. She does not 
presently appear to be stable for transfer from the short-term acute care hospital due to her worsening anemia 
and ongoing need for blood transfusion. Continued care in the short-term acute care hospital is appropriate until 
the enrollee is stable to transfer. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of LTACH 
admission. The Plan denied your request. The Plan says the admission was denied as not meeting criteria, not 
medically necessary, and continued acute hospital stay was offered, until you could discharge to a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with acute systolic congestive heart failure. The record indicates 
that you are improving but still require acute care services before transitioning to a lower level of care. You are 
receiving appropriate care at the present setting and you do not require services at the LTACH that are not 
available at the acute care facility where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nephrology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the nephrology services. You say that the enrollee was treated prior by you, 
and you would like to develop a treatment plan. The Plan denied your request. The Plan says the requested 
provider is an OON provider and there are 2 in-network providers that are accepting new patients. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the nephrology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray on March 30, 2022. 
 
You asked the Plan to waive the copayment for X-ray. You say that you would like the claim reviewed again 
for additional payment. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $95 
copayment for basic radiological services at outpatient hospital. Covered services include, but not limited to: 
X-rays. The provided billed in the amount $424 and the Plan paid $335.20. $424 - $335.20 = $88.80. This is 
less than the copayment. Therefore, results in the total cost sharing amount of $88.80. 
 
You have been asked to pay a $88.80 copayment, which is less than the copayment amount for X-ray. X-rays 
fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 waive the copayment for X-ray on March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that you are requesting this 
appeal to rule out carotid artery disease. The Plan denied your request. The Plan says the requested test is not 
reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that cerebrovascular arterial studies may be considered 
medically necessary if one or more of the signs and symptoms listed in the Medicare rules section above are 
present. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that this request will be considered not medically necessary based on the provided 
documentation. Our physician reviewer found carotid bruit or signs or symptoms of transient ischemic attack 
(TIA) or cerebral vascular accident (CVA) to justify this test are not documented. Our reviewer also found that 
the history suggests an internal ear cause, but without testing for vertigo or side effects of medications ruled 
out, it is not appropriate to order a duplex study. 
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you would like to be transported an 
additional 2 miles, totaling 77 miles. You also say that it is very important for you to see the provider at this 
location. The Plan denied your request. The Plan says the mileage from your home to the requested clinic 
avoiding tolls, highways and ferries is a total of 85.5 miles which is 10.5 miles over your allowed benefit. The 
Plan also says the mileage from your home to the requested clinic not avoiding tolls, highways and ferries is a 
total of 76.5 miles which is a total of 1.5 miles over your allowed benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 75 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Drive Nitro 3 wheeled walker for the enrollee. 
 
You asked the Plan to pre-approve Drive Nitro 3 wheeled walker. You say that the enrollee's current device is 
too wide to fit through the passageways inside her home as well as the entrances to her apartment building. The 
Plan denied your request. The Plan says that the enrollee received a heavy duty wheeled walker and a 3 
wheeled walker in May and June of 2022, respectively, and the enrollee received a power scooter in December 
2021. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have two walkers and a power scooter. Two walkers and a power scooter serve the 
same purpose as Drive Nitro 3 wheeled walker. Therefore, we decided that the Plan does not have to pre-
approve Drive Nitro 3 wheeled walker for the enrollee.