Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311). 
 
 You asked the Plan to pre-approve the upgraded electronics. You say that you are appealing the denial of a 
powered wheelchair with captains seat and tilt feature. The Plan denied your request. The Plan says the 
approved power options come with their own switches. It is not medically necessary to control power options 
through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records document that the enrollee has 3/5 to 4/5 upper extremity 
strength and is independent with feeding thus indicating she has adequate upper extremity strength and function 
to operate the wheelchair's power options with their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Gene Panel testing provided on January 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for Gene Panel testing. You say that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says There are currently no clinical indications for this technology. Experimental procedures and items are defined as "those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community."

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 Gene Panel testing provided on January 11, 2021 by an out-of-network (OON) provider.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. 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 Coflex interlaminar stabilization device (CPT 
code(s): 22867 and 22868). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Coflex Interspinous device in the 
setting of spinal stenosis have 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device is experimental. High failure rates with similar devices have been reported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Coflex interlaminar stabilization device (CPT code(s): 22867 and 22868).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
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 a Group 3 PWC with multiple power options 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 criteria for coverage are not met. Our physician reviewer found the records do not show that the enrollee is 
at high risk for development of a pressure ulcer or utilizes intermittent catheterization for bladder management. 
She does not have documented increased tone or spasticity to meet the criteria for the power tilt accessory. The 
requested Group 3 PWC 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 a Group 3 power wheelchair (PWC) with multiple power options.
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 you need intensive PT because you have paralysis 
and you also had your toes amputated, which makes it difficult to balance. The Plan denied your request. The 
Plan says you are at home receiving home health therapy services and have not had any recent hospital stays. 
The plan says you are medically stable. 
 
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 based on the medical records provided there is no documentation that you 
require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services (83789) provided on October 
4, 2021. 
 
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says this code is not eligible 
for reimbursement when billed for specimen validity testing on specimens used for drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for the laboratory testing services (83789) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. His physical function is at or near his baseline. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) for tooth #26 provided by 
an out-of-network provider on December 27, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that the Plan should pay up to $3,000 after 
your $50 deductible is paid. The Plan denied your request. The Plan says the benefit limit for D2332 has been 
met and 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. The Plan covers 2 resin-based 
composite per 12-month period.  
 
We looked at the file and Medicare rules. D2332 was met and exhausted with teeth #23 and #24 on December 
27, 2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite for tooth #26 have not been met. Therefore, we decided that the Plan does not have to pay for a resin-based 
composite (D2332) for tooth #26 provided by a participating provider on December 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-
approve LTACH services.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the ECG provided on February 2, 2022. We also 
decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 
3, 2022.  
 
You asked the Plan to waive the copayments for the specialist visit and ECG. You say that the services should 
have been paid based on previous visits. The Plan says that you have been charged the correct cost sharing 
amount. 
 
We decided that the Plan has to reduce the copayment for the ECG provided on February 2, 2022.  
 
You have been asked to pay $115.98 for the ECG. Based on the Plan contract however, you cannot be asked to 
pay more than a $50 copayment for non-radiological diagnostic tests. This cost sharing is a contractual 
agreement you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan has to reduce 
the copayment to $50 for the ECG provided on February 2, 2022. 
 
We also decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on February 3, 2022. 
 
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 $50 
copayment for the specialist visit. 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 office 
visit provided on February 3, 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 pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that this procedure is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested radiofrequency ablation to 
the sacroiliac joint is not medically reasonable and necessary - experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 69-year-old male diagnosed with sacroiliac joint arthropathy. 
The provider is requesting coverage for the enrollee to undergo an SI joint RFA procedure. 
 
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 RFA of the SI joint 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extractions (D7140) provided on December 22, 2021. 
 
You asked the Plan to pay for the extractions. You say that you were told these services were necessary for an 
upcoming surgery. The Plan denied your request. The Plan says these services are not covered by your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 dental 
extractions (D7140) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to provide additional payment for the frames, progressive polycarbonate lenses 
with anti-reflective coating and vision supply, accessory and/or service up to your $150 vision benefit. We 
decided that the Plan does not have to provide additional payment beyond you $150 benefit.  
 
You asked the Plan to provide additional payment for the eyeglasses. You say that you would like your $150 
benefit applied to your eyewear. The Plan says that your $150 vision benefit was already applied to your 
routine eyewear. 
 
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 $150 for eyeglasses or contact lenses each year. 
 
We reviewed the file and the Plans rules. The documentation provided by the Plan shows that the Plan paid 
$90 toward the cost of the eyeglasses purchased January 14, 2022. Therefore, we decided that the Plan has to 
provide additional payment for the eyeglasses up to the $150 vision benefit limit. The Plan does not have to 
provide payment beyond the $150 vision benefit. 
 
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 facet injection services. 
 
You asked the Plan to pre-approve facet injection services. You say that the records provided support the need 
for the requested injection services. The Plan denied your request. The Plan says the requested injection 
services are not supported because the clinical information does not show the enrollee has predominantly axial 
pain that is not associated with radiculopathy or neurogenic claudication. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are only considered 
medically reasonable and necessary for the diagnosis of chronic pain in patients who have an absence of 
untreated radiculopathy or neurogenic claudication.  
 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 facet injection services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic 
low back pain and has done physical therapy. The enrollee's medication trials include Ultracet, Mobic, 
Gabapentin, Diclofenac and Tizanidine. The notes indicate radicular pain into the left thigh. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet injection services.