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

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of low back pain with multiple etiologies has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation 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. 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 Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you do not drive due to your health conditions. 
You say that you need more rides in order to get to your doctor appointments. You also say that you cannot 
afford to pay for a cab ride every time you have an appointment or need to go to the pharmacy. The Plan denied 
your request. The Plan says additional trips beyond the allowed number each year are not covered. 
 
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 a maximum of 60 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 16 additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services for the enrollee. 
 
You asked the Plan to pre-approve ambulance services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the physician's office is not a covered destination. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that ambulance services are not medically reasonable and necessary. The documentation does not support that 
other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are 
contraindicated for this patient. The documentation does not support that the patient needs the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
ambulance 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 ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ambulance services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiologist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the cardiologist office visit. You say that you would like a second opinion 
from a different provider. The Plan denied your request. The Plan says the requested provider is an OON 
provider, and a list of multiple in-network providers that have been approved was given to the enrollee. 
 
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 cardiologist office visit to be provided by an out-of-network (OON) provider.  
 
Your complaint about your experience with the in-network provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve personal care services. The Plan denied your request. The Plan says 
personal care services is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Although personal care services are not covered under 
your Medicare benefits, they may be eligible for coverage under your Medicaid benefits. Therefore, we decided 
that the Plan does not have to pre-approve personal care services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab test (81232) billed with date of service December 21, 
2021. 
 
You asked the Plan to pay for lab services. You say that this lab was necessary and was billed appropriately. 
The Plan denied your request. The Plan says the records show that the date of specimen collection in this case 
was November 29, 2021. Medicare rules say that lab services should be billed with the date of specimen 
collection as the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that generally the date of service for clinical laboratory services should be billed for the date the 
specimen was collected. 
 
We find that the billed date of service of December 21, 2021, is not supported in the medical record. Specifically, the medical record indicates that the specimen used for this test was collected on November 29, 
2021. Based on this information, we decided that Medicare billing rules for lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab test (81232) billed with date of service 
December 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of attendant care services (S5125). 
 
You asked the Plan to pre-approve additional hours of attendant care services. The Plan denied your request. 
The Plan says your level of function and needs no longer meet the requirements for 34 hours of personal 
attendant services per week. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional hours of attendant care services have not been met. Specifically, we find that the 
services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not 
have to pre-approve additional hours of attendant care services (S5125).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy provided on October 27, 2021. 
 
You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the 
Act).  
 
 
 
 We looked at the file and Medicare rules. Per NCD 270.6, the requested infrared therapy is not a covered 
benefit. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have 
not been met. Therefore, we decided that the Plan does not have to pay for the infrared therapy provided on 
October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the facet joint injections. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 where there is no non-facet 
pathology per clinical assessment or radiology studies that could explain the source of the patients pain, 
including but not limited to fracture, tumor, infection, or significant deformity. 
 
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 facet joint injections. Our reviewer 
says that the injections are not medically necessary. Our physician reviewer found the records do not show that 
the enrollee does not have an absence of non-facet pathology. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64490, 64491).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroplasty and/or transposition of the median nerve at 
the carpal tunnel. 
 
You asked the Plan to pre-approve neuroplasty and/or transposition of the median nerve at the carpal tunnel. 
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 neuroplasty and/or transposition of the 
median nerve at the carpal tunnel. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there are very limited objective 
examination findings to corroborate right carpal tunnel syndrome. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested neuroplasty and/or transposition of the median nerve at the carpal tunnel, in this case, is 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 neuroplasty and/or transposition of the median nerve at the carpal tunnel have not been met. Therefore, we decided that the Plan does not have to pre-approve neuroplasty and/or 
transposition of the median nerve at the carpal tunnel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the mechanism is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the seat lift mechanism. Our reviewer 
says that the seat lift mechanism is not medically necessary. Our physician reviewer found the record shows the 
patient has no difficulty with seat to stand transfers. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like Plan to approve this 
denture. 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 February 21, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) 
provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test (91065). 
 
You asked the Plan to pre-approve the breath test. You say that the breath test is medically necessary. The Plan 
denied your request. The Plan says the requested breath test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth and measuring small bowel transit time is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the breath test have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a hydrogen breath test (91065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional acupuncture visits. 
 
You asked the Plan to pre-approve the acupuncture visits. You say that acupuncture is the only treatment that 
has helped with your low back pain. The Plan denied your request. The Plan says you must complete the 12 
visits before you can be evaluated for more. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan approved five additional visits for a total of 
12 covered visits. Additional visits cannot be reviewed until all 12 visits are completed. Therefore, we decided 
that the Plan does not have to pre-approve 15 additional acupuncture visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Peripheral nerve stimulator trial for the enrollee to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no network deficiency for these 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 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 Peripheral nerve stimulator trial for the enrollee to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional ostomy supplies including 120 ostomy 
pouches, ostomy skin barrier, transparent film, 120 ostomy skin barriers with flange, 300 adhesive remover 
wipes, and 150 skin barrier wipes. 
 
You asked the Plan to pre-approve additional ostomy supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested supplies are medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additional ostomy supplies are only covered for 
certain indications. 
 
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 additional ostomy supplies. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the enrollee have a colostomy. The documentation does not indicate 
why such a high amount of these items is needed. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ostomy supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional ostomy supplies including 120 ostomy pouches, ostomy skin 
barrier, transparent film, 120 ostomy skin barriers with flange, 300 adhesive remover wipes, and 150 skin 
barrier wipes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis for the enrollee. 
 
You asked the Plan to pre-approve Lucentis. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no indication Avastin/bevacizumab would likely be less 
effective, and/or cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our reviewer says that 
Lucentis is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
bevacizumab. There is no indication that bevacizumab would likely be less effective and/or likely have adverse 
effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy 
criteria for Lucentis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 16, 
2021. 
 
You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says the benefit limit has been 
exceeded. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided on January 5, 2021, less than 12 months prior to the visit at 
issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) 
you had on December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional miles. 
 
You asked the Plan to pre-approve additional mileage. You say that you need the ride to your appointment. 
You say that it was denied. You also say that you rescheduled the appointment for a different location that is 63 
miles away. The Plan denied your request. The Plan says additional mileage beyond the approved distance is 
not covered. 
 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 a maximum of 50 miles trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 20 additional miles.