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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has underlying dementia. The Plan 
denied your request. The Plan says the enrollee has not been diagnosed with AD or FTD. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that 
the PET scan of the brain is not medically necessary. Our physician reviewer found that the records provided 
for review did not support that the enrollee currently meets criteria for either AD or FTD let alone both. In as 
much it cannot be said that the enrollee has a condition for which the NCD supports performance/provision of 
this service. Therefore, the request does not meet criteria for coverage. 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
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's medical condition and 
complex medical needs warrant the intensity of services offered in the long-term acute care setting. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently 
unstable for transfer 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs. 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brukinsa. 
 
You asked the Plan to pre-approve Brukinsa. You say that you need this treatment once you are released from 
the hospital. The Plan denied your request. The Plan says the drug is not eligible for coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Brukinsa.  
 
 
 Benefits for Brukinsa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device was prescribed to help 
manage the enrollee's complicated respiratory needs at home. The Plan denied your request. The Plan says the 
request for a home mechanical ventilator set in AC mode with very low tidal volumes that could be delivered 
by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
pulmonary fibrosis. A single ABG from May 2022 does not show hypoventilation. The Life2000 system is not 
a true ventilator because it is not capable of providing full ventilatory support.  There is inadequate evidence of 
safety and efficacy of this device in the treatment of chronic lung disease. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic image 
(D0350) provided on October 26, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not covered under your plan. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two-
dimensional (2D) oral/facial photographic image (D0350) provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation (D9243) provided on November 6, 2022. 
 
You asked the Plan to pay for sedation. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied service is not a covered benefit. 
 
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 pay for sedation 
(D9243) provided on November 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner visits provided on July 13, 2022 to July 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for practitioner visits. You say that it is the facility's responsibility to obtain 
authorization. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for practitioner visits provided on July 13, 2022 to 
July 16, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the enrollee may have inconsistent chemicals in 
their lab results. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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 February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on October 6, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you believe the Plan should help you 
with your payments for this service. The Plan denied your request. The Plan says this service is not a covered 
expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service 
to verify benefits and provider eligibility. 
 
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 pay for the full 
mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) 
provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve a lntracept Procedure. You say that the requested procedure fills a treatment 
gap for those enrollees that do not receive adequate relief from traditional conservative methods and don't have 
instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says 
unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of 
efficacy. 
 
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 lntracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for vertebrogenic low back pain. She presented with 
pain in the low back, buttock, groin, leg, hip, calf, ankle, and foot. In this case, there were/are multiple 
plausible pathologic sources of significant pain generation. Additionally, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care measures. The 
back pain, the noted pain-aggravating factors (sitting), pain-relieving factors (medications and standing), and 
intact neurologic exam were/are all non-specific to any pathologic entities. Overall, documentation was/is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 lntracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (64628). 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that the requested procedure fills a 
treatment gap for those enrollees that do not receive adequate relief from traditional conservative methods and 
don't have instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The 
Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient 
evidence of efficacy. 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented with low back pain. The enrollee mostly has axial back pain 
with very little intermittent radicular symptoms. In this case, the requesting provider notes Modic type II 
changes at the L5 and S1 vertebral bodies; however, this is not on the formal diagnostic study. Additionally, 
there were/are multiple plausible pathologic sources of significant pain generation. The mainly axial back pain, 
the noted pain-aggravating factors (standing and walking), pain-relieving factors (laying, sitting, and heat), 
along with the limited objective exam were/are all non-specific to any pathologic entities. Overall, 
documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time.  There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraosseous ablation of the basivertebral nerve (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on July 20, 2022, and August 
17, 2022. 
 
You asked the Plan to pay for the services provided. You say that you did not know the hospital would be 
charging you. The Plan denied your request. The Plan says the services are excluded from coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL or 
P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C/P-
C IOL and a conventional IOL.  
 
We looked at the file and the rules. The payment for the insertion of a conventional IOL furnished in a hospital 
outpatient department is packaged into the payment for the surgical procedure. However, for the facility charge 
for the insertion of a A-C IOL or P-C IOL, you are responsible for the portion of payment that exceeds the 
facility charge for the insertion of a conventional IOL.   
 While both a A-C IOL and a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the 
astigmatism-correcting or presbyopia-correcting features of an IOL. Therefore, we decided that the Plan does 
not have to pay for the vision services provided on July 20, 2022, and August 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve colonoscopy. You say that the enrollee is already having an endoscopy on 
the same day and you want to add this service. The Plan denied your request. The Plan says this provider is out-
of-network with the Plan and the enrollee can be treated within the Plan network. 
 
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 
a diagnostic colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental service provided on September 7, 2022. 
 
You asked the Plan to pay for dental service. You say that you are requesting payment. The Plan denied your 
request. The Plan says the Plan is the secondary payer for you and cannot pay this claim until it has been 
processed by the primary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
with the provider that this claim was submitted to your primary insurance carrier for payment. As the secondary insurer, the Plan cannot be held responsible for dental service until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for dental service 
provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with adjustable height 
armrest. 
 
You asked the Plan to pre-approve Group 2 power wheelchair. You say that you struggle to walk long 
distances. The Plan denied your request. The Plan says there is a lack of information to support that you do not 
have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 2 power wheelchair. Our 
reviewer says that you do not meet the Medicare criteria for the requested Group 2 power wheelchair. Our 
physician reviewer found the evidence does not show that you are unable to use a manual wheelchair. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair with adjustable height armrest.
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 you are no longer walking independently and need 
additional care to restore your health, to walk again, and to get back to daily activities. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting 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 not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.