Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture services provided from August 25, 2022, to October 
18, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that each time you go, the same services are 
given, and there is no reason to start denying portions of your bills. The Plan denied your request. The Plan 
says that you exhausted your benefit of 12 office visits on date of service August 23, 2022. The Plan also says 
that you received additional alternative care on September 8, 2022, September 20, 2022, and October 13, 2022, 
that were beyond the 12 visits allowed per calendar year and that were not approved by the Plan on a separate 
pre-authorization request. 
 
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 records do not support that the Plan paid for 12 acupuncture visits for the 
2022 calendar year. This means that the Plan has not provided a valid reason for denying payment of the 
acupuncture services. The documentation provided by the Plan does not demonstrate or support that the benefit 
was exhausted on the dates of service in dispute. It is the burden of the Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the acupuncture services provided from August 25, 2022, to October 18, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
shows foraminal stenosis and facet degenerative joint disease. The cause of the enrollee's back pain is unclear. 
The Intracept procedure is therefore 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 an Intracept procedure.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942) provided on 
February 1, 2022. 
 
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that it was important to 
use image guidance to perform a successful injection. The Plan denied your request. The Plan says that charges 
for or in connection with services or supplies that are, as determined by the Plan, considered to be experimental 
or investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the ultrasonic guidance for needle 
placement. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a complex spine including hardware and 
scoliosis. Our reviewer also found that as the sacroiliac joint was the target, ultrasound guidance to ensure 
proper needle placement at the intended site was reasonable and should be paid. 
 
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 ultrasonic guidance for needle placement have been met. Therefore, we 
decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942) provided on February 
1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on September 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
global period of code 10061. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. The requested services (99232) are included in the global surgery 
period for the procedure (10061) provided on the same date. 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 the services (99232) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the diagnostic testing services provided on March 1, 2022. 
 
You asked the Plan to pay for the diagnostic testing services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that intraoperative neurophysiological testing may be used 
to identify/prevent complications during surgery on the nervous system, its blood supply, or adjacent tissue. 
 
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 diagnostic testing services. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the enrollee underwent C5-C6 
decompressive laminectomy with fusion and internal plate fixation. The review has determined that the criteria 
for coverage were met. The service was medically necessary to evaluate for cord compression. 
 
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 diagnostic testing services have been met. Therefore, we decided that the 
Plan has to pay for the diagnostic testing services provided on March 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's teeth are shifting due to 
extractions and these services are required to restore proper chewing function. The Plan denied your request. 
The Plan says the enrollees 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 the enrollees benefit for the requested item or service was exhausted on date of service September 7, 
2019. Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) 
and mandibular partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (93313) provided on July 12, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the records submitted do not support procedure code 93313. 
 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 service. Our physician reviewer found 
the documentation submitted was reviewed and does not meet criteria. Per National Correct Coding Initiative 
(NCCI) Chapter II, "93312-93317 (Transesophageal echocardiography when used for monitoring purposes) 
However, when performed for diagnostic purposes with documentation including a formal report, this service 
may be considered a significant, separately identifiable, and separately reportable service". Medicare record 
does not include a formal report to support a significant separate service, and therefore, would be included in 
the anesthesia service 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the echocardiography (93313) provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve replacement services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter mitral valve replacement services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from October 7, 2022, to 
December 16, 2022. 
 You asked the Plan to pay for the therapy services. You say that these services were medically necessary and 
were pre-approved starting in September, "as ordered". The Plan denied your request. The Plan says the 
services at issue were no longer medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee had previously been treated with in-home and outpatient 
therapies and should have been independent with a home exercise program. There is no documentation that the 
enrollee continued to require outpatient therapies from a non-contracted provider during the dates in question. 
The additional therapy services were not an appropriate duration and frequency for treatment of the enrollees 
medical condition and therefore are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for physical therapy services provided from October 7, 2022, to December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says drugs that are not supplied by a provider office are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not require the services of a skilled physical therapist without documented improvement in function, range 
of motion and motor strength. The enrollee can receive assistance for mobility and daily activities in their 
current setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genetic Technological Innovations urinary tract infection 
(UTI) panel provided on December 2, 2021. 
 
You asked the Plan to pay for the UTI panel. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the UTI panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the Genetic Technological Innovations urinary tract infection (UTI) panel provided on 
December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the Medicare criteria for admission to an Inpatient Rehabilitation 
Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
dizziness and atrial fibrillation. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial of this procedure is 
unwarranted and unsupported based on the enrollee's current medical status and available data and is 
inconsistent with currently accepted medical practice. The Plan denied your request. The Plan says the 
requested SPRINT neurostimulator is not medically necessary and continues to be studied to determine safety 
and 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 SPRINT PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The SPRINT neurostimulator is experimental for bilateral shoulder pain. 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 the SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system (64555).
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 requesting reconsideration for the denial of 
an IRF admission. You say the physicians recommended inpatient rehabilitation to have all therapy aggressive. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an IRF. 
 
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 does not require intensive rehabilitation and cannot rehabilitate the arm 
for two to three weeks because they are non-weight bearing. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an 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 magnetic resonance imaging (MRI) shows disc protrusions impinging on nerve 
roots. The cause of the back 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a superion vertiflex device. 
 
You asked the Plan to pre-approve a superion vertiflex device. 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 superion vertiflex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the superion vertiflex device is 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 superion vertiflex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a superion vertiflex device.