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

We decided that the Plan does not have to pre-approve a genicular nerve block using imaging guidance for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence to support the use of this procedure.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational for post-operative chronic knee pain and is the subject of on-going clinical trials. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block using imaging guidance for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided May 21, 2021.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99152 is sedation services provided by the same
physician or other qualified health care professional performing the diagnostic or therapeutic service that the
sedation supports, requiring the presence of an independent trained observer to assist.
We find that CPT code 99152 is not supported in the medical record. Specifically, the record does not
document the presence of a trained observer to assist. Based on this information, we decided that Medicare
rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not
have to pay for sedation services (99152) provided May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a standard wheelchair (K0001), anti-tipping device (E0971), wheel lock brake extension (E0961), heel loop/holder (E0951), adjustable height detachable armrest (E0973) and non-standard seat frame and cushion (E2201)
You asked the Plan to pre-approve these items. You say that this is medically necessary/ The Plan denied your request. The Plan says that the details we got from your doctor don't meet Medicare guidelines that show a medical reason you need a standard wheelchair and accessories.
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 has not provided any medical records for review. Without medical records we are unable to substantiate the Plan's medical necessity denial. Therefore, we decided that the Plan has to pre-approve a standard wheelchair (K0001), anti-tipping device (E0971), wheel lock brake extension (E0961), heel loop/holder (E0951), adjustable height detachable armrest (E0973) and non-standard seat frame and cushion (E2201)
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 the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture.

You asked the Plan to pre-approve the upper and lower partial denture. The Plan denied your request. The Plan says dentures are limited to one set every 5 years.

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, you also have a maximum benefit of one set of dentures every five years. The Plan paid for the dentures provided on February 15, 2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant control (CPT code E2311), power seat lift (CPT code E2300), expandable controls (CPT code E2377), expandable control for joystick Q logic 3 (CPT code K0108), power positioning electronics (CPT code E2311), transit kit (CPT code K0108), and height adjustable receive joystick bracket (CPT code K0108), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Attendant control (E2311) - per Medicare rules an attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary is unable to operate a manual or power wheelchair and their caregiver is unable to operate a manual wheelchair but is able to operate a power wheelchair. In this case, per the appeal, this enrollee is able to safely operate a power wheelchair controller, therefore an attendant controller would not be covered. Power seat lift (E2300)- per Medicare rules, a power elevating seat is not covered, in addition, electrical connections and controls that are to power and control a power elevating seat are not covered. Expandable controls (E2377), expandable control for joystick Q logic 3 (K0108) and power positioning electronics (E2311) these devices are not covered. We recognize that the group 3 power wheelchair will need more complex expanded controls and electronics to power the tilt and recline and power elevating leg rests, v
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the claim. The 
Plan denied your request. The Plan says no separate payment is made per Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. When these services are covered, payment for them is 
subsumed by the payment for the services to which they are incident. Therefore, we decided that the Plan does 
not have to pay for the medical services provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 enrollee is morbidly obese with a
body mass index (BMI) of 40 and chronic back pain. She had prior lumbar fusion and kyphoplasty as well as
prior placement of an interspinous spacer at L3 to L4. The enrollee has contraindications of the proposed
procedure, morbid obesity and osteoporosis. The procedure is also not supported by two orthopedic learned
societies. The services are 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 Vertiflex Superion spacer
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require transfer to the LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee was admitted with hypoxic respiratory failure. The record indicates that the enrollee is weaning from bilateral positive airway pressure (BiPAP) and that a hospice referral is pending. 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 he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 admission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health occupational therapy visits.
You asked the Plan to pre-approve 7 home health occupational therapy visits. You say that this service is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 7 home health occupational therapy visits. Our reviewer says that the requested home health occupational therapy services are not medically reasonable and necessary. Our physician reviewer found Based on the documentation provided, the enrollee does not have documented home health occupational therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the requested home health occupational therapy services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health occupational therapy visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on July 27, 2021. 
 
You asked the Plan to pay for the dental item. You say that you never received the partial denture in 2018. You 
say that it was denied. You also say that according to your dental records show you did not receive the partial 
denture. The Plan denied your request. The Plan says the partial upper denture is covered once every 5 plan 
years. The Plan also says that the frequency limit has been exceeded. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental item have not been met. Specifically, the frequency limitation has been exceeded. The 
record shows that the Plan paid for a partial upper denture that you received on November 18, 2019. Therefore, 
we decided that the Plan does not have to pay for the partial upper denture (D5213) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment you rented from
January 15, 2021, to July 15, 2021.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you have asked them to
pick these items up because you didn't want them. The Plan denied your request. The Plan says you were
charged this coinsurance correctly. The records show that you have not returned these items to the provider, so
you are responsible for this coinsurance until you do so.
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 20%
coinsurance for durable medical equipment.
You have been asked to pay 20% coinsurance for the oxygen equipment. The oxygen equipment falls within
the durable medical equipment 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 coinsurance for
the oxygen equipment you rented from January 15, 2021, to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 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 sacroiliac joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve the MBBs. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MBBs are covered for the indications established in 
the applicable LCD. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically reasonable and necessary.  
 
Our physician reviewer found that in this case, there has been no follow-up to assess the enrollee's response to 
physical therapy. The review has determined that the requested diagnostic MBBs are not medically reasonable 
or necessary according to the coverage criteria established in the LCD. 
 
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 MBBs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve medial branch blocks (MBBs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the genicular RFA. The Plan denied your request. The Plan says this is 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 the genicular RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that both thermal and cooled genicular radiofrequency ablation are being evaluated in the treatment of chronic knee pain for individuals that have not been effectively managed by pharmacologic or other alternative therapies. There is a lack of adequately designed trials in the peer-reviewed literature concerning the use of radiofrequency ablation as definitive treatment for chronic knee pain. 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 genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 22, 2021, and July 13, 2021.

You asked the Plan to pay for the laboratory services. You say that the referring provider is a contracted physician in the Plan's network. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent or emergent.

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 record shows the referring provider is also 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 the laboratory services provided on June 22, 2021, and July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 14,
2021.
You asked the Plan to pay for the dental service. You say that you were told at the start of the year that you had
$500 for dental services. You say that you were not informed of any restrictions. You also say that you did not
misuse your coverage on purpose. The Plan denied your request. The Plan says 1 limited oral evaluation is
covered per plan year. The Plan also says that the frequency limit has been exceeded. 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 and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you
received on April 16, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation (D0140) provided on July 14, 2021.