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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation for the sacroiliac joint (SIJ) (for 
low back/pelvis pain) (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this type of injection is considered experimental /investigational. The Plan 
states this means that it has not been shown to be safe and effective. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for 
the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ 
pain.  Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has 
determined that the requested SI joint RFA 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation for the sacroiliac joint (SIJ) (for low back/pelvis pain) (CPT code 
64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on November 26, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you did not realize the 
copayment is $35 for each visit. You say that you thought the copayment was $10 for each visit and you had to 
quit physical therapy because you cant afford it. The Plan denied your request. The Plan says the copayment 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 $35 
copayment for in-network, Medicare covered therapy visits. 
 
You have been asked to pay $35 copayment for the physical therapy visits. Physical therapy falls within the 
Outpatient rehabilitation services 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 
physical therapy on November 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from November 19, 2021, 
to November 20, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient admission was 
medically necessary. The Plan denied your request. The Plan says there was no documentation provided to 
support the expectation the enrollee would have required a 2 midnight stay. The Plan also says that there were 
no post-operative issues beyond pain management, and the enrollee was discharged the day after surgery. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee underwent bilateral breast expander removal, right breast 
capsulectomy and debridement, and bilateral breast implant placement on November 19, 2021. Per the 
documentation, the enrollee tolerated the procedure well without complications and was taken to recovery in 
stable condition. Our reviewer found that the enrollee was received in recovery with normal respiratory rate 
and adequate oxygenation. Her blood pressure and heart rate are noted to be stable. Our physician reviewer also 
found that the record did not show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient admission provided from November 19, 2021, to November 20, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for an inpatient admission. The Plan denied your request. The Plan says they have approved the right 
shoulder arthroplasty but that it can be performed on an ambulatory/observation basis. The Plan says that there 
is no need to prospectively approve the inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are 
met in this case. Our physician reviewer found the requested reverse total shoulder arthroplasty is documented 
to have been supported. However, detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. Therefore, the record does not show that at the time of the request for an inpatient admission, 
the admitting physician reasonably expected that the enrollee's necessary hospital care would span two 
midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit on September 23, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you don't want to pay for the 
doctors visit because the doctor never reached out to tell you the CPAP unit you received was defective. The 
Plan denied your request. The Plan says the copayment applied was 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 $35 
copayment for a specialist visit.  
 
 
 
 
 
 
 
 You have been asked to pay a $35 copayment for a specialist visit. A specialist office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 the specialist visit on September 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for Medicare Part B drugs provided on July 8, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were treated in the 
emergency department and feel you should only be charged an emergency room copayment. The Plan denied 
your request. The Plan says that the coinsurance applied was correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records proving this was not an emergency 
room visit. Therefore, we decided that the Plan has to waive the coinsurance for Medicare Part B drugs 
provided on July 8, 2021.  
 
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: Favorable

 
We decided that the Plan has to pre-approve allograft, morselized, or placement of osteopromotive material 
(20930) and removal of spine fixation device (22852, 22855) 
 
You asked the Plan to pre-approve the requested surgical procedures. You say that these procedures are 
medically necessary. The Plan denied your request. The Plan says that a decision was not made timely 
regarding these services. 
 
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 pre-approve the requested surgical procedures. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the records show failure of previous fusion. Surgery to revise is indicated and the 
use of a fusion enhancer (although off-label) shoudl be approved. BMP is the best product available for 
revision lumbar fusion surgery and should be approved for use in cases of previous fusion failure which is 
appropriately documented. 
 
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 requested surgical procedures have been met. Therefore, we decided that the 
Plan has to pre-approve allograft, morselized, or placement of osteopromotive material (20930) and removal of 
spine fixation device (22852, 22855)  
 
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 pre-approve an epidural steroid injection (ESI). 
 
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 an ESI is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
history of neck pain since 2000. An electromyelogram (EMG) on January 13, 2022 showed no evidence of 
nerve root pinching (radiculopathy). You had a prior medial branch block injection with limited relief. There is 
no x-ray evidence of disc displacement on the most recent magnetic resonance imaging (MRI). The criteria for 
coverage are not met and the ESI is 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 epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit for an eye exam (99213) 
provided on November 1, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that that you disagree with the charges 
because you did not see the provider you requested. The Plan denied your request. The Plan says the 
copayment 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 $15 
copayment for one annual routine eye exam. If you receive services that address a medical condition during the 
same office visit, you pay a $15 specialist office visit copayment.  
 You have been asked to pay a $15 copayment for an office visit. The EOC confirms that $15 is the required 
copayment for this service. 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 an office visit for an eye 
exam (99213) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 5, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing 
aids ordered through providers other the Plan's hearing provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans hearing provider.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a room air purifier (E1399). 
 
You asked the Plan to pre-approve a room air purifier. You say that you have allergies and are allergic to pollen 
and particles that are in the air, which come inside your house. You also say that your allergies make you blow 
your nose, and you bleed from your nose. The Plan denied your request. The Plan says the room air purifier is 
not covered because it is not medical in nature and is regularly and primarily used by persons who do not have 
a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a room air purifier (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says Xiidra is a self-
administered drug and does not fall under Part B coverage. 
 
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 Xiidra.  
 
Benefits for Xiidra 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 2021 wellness allowance for an exercise class 
(S9451) provided on February 4, 2021. 
 
You asked the Plan to reimburse you for exercise class. You say that you never received your reimbursement. 
The Plan denied your request. The Plan says your first reimbursement request was approved and paid while 
you were resubmitting the reimbursement with proof of payment that was requested. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses you up to 
$150 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered 
instructional fitness classes, participation in wellness programs memory fitness activities, acupuncture and/or 
covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. 
 
 The Plans rules for coverage of gym benefits have not been met. The records show that the Plan has 
reimbursed you $150 for the wellness allowance for 2021. The records also show that additional 
reimbursement would exceed your benefit. Therefore, we decided that the Plan does not have to reimburse you 
for the 2021 wellness allowance for an exercise class (S9451) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trifocal lens (V2300), frames (V2020), spherocylindrical 
lens (V2303), and anti-reflective coating (V2750), provided on December 9, 2021. 
 
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your 
request. The Plan says you have exceeded the Plan's maximum allowance and are responsible for the 
difference. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $150 allowance towards the purchase of eyewear every year. 
 
We looked at the file and the Plan's rules. The total cost for the eyeglasses were $539., the benefit of $150 
allowance was applied to the purchase, leaving you with a members responsibility of $389. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the trifocal lens (V2300), frames (V2020), spherocylindrical lens 
(V2303), and anti-reflective coating (V2750), provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TEN full antibiotic resistance and pathogen 
detection testing by nucleic acid for urinary tract infection (UTI) provided on September 20, 2021. 
 
You asked the Plan to pre-approve the UTI panel. You say that this testing was necessary due to the enrollee's 
suspected UTI. The Plan denied your request. The Plan says there is no clinical evidence showing beneficial 
outcomes from using this testing routinely 
 
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 UTI panel. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had symptoms of urinary frequency and was treated with 
antibiotics. The record does not indicate that the requested test was intended to be used for management 
purposes or that it would alter the management of the enrollee. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 UTI panel have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the TEN full antibiotic resistance and pathogen detection testing by nucleic acid for 
urinary tract infection (UTI) provided on September 20, 2021.