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

 
We decided that the Plan does not have to pre-approve a scooter (K0812). 
 
You asked the Plan to pre-approve a scooter. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a POV is covered if all of the basic coverage criteria 
(A-C) have been met and if criteria D-I are also 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 a scooter. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found there is no documentation that the enrollee 
meets the Medicare criteria for medical necessity for the requested power scooter. The enrollee presently has a 
power wheelchair from 2021, it is not clear from the provided records that the enrollee can safely transfer on 
her own to qualify for the power scooter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter (K0812).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision of dental implants (CPT code(s): D4261 and 
D9951). 
 
You asked the Plan to pre-approve the dental services. You say that you have a moderate form of peri-implant 
disease and surgical treatment will be necessary. The Plan states the procedure will reduce pocketing to provide 
more stability and allow you to have better access to clean properly. The Plan denied your request. The Plan 
says the services are not covered by Medicare or the health plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Review of the records show that you do not meet the Medicare criteria. The Plan will pay for dental services 
that are a part of a covered procedure (e.g., a broken jaw following accidental injury) and they will pay for 
dental services for extractions done in preparation for radiation treatment for cancer. Therefore, we decided that 
the Plan does not have to pre-approve a revision of dental implants (CPT code(s): D4261 and D9951).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgrade to a biventricular pacemaker. 
 
You asked the Plan to pre-approve an upgrade to a biventricular pacemaker. You say that it is medically 
necessary for the enrollee to receive this device. The Plan denied your request. The Plan says the criteria for an 
upgraded pacemaker have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an upgrade to a biventricular 
pacemaker. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the appropriateness and medical necessity of 
changing the patients dual chamber pacemaker and replacing it with a biventricular pacemaker in order to 
reduce RV pacing frequency. Left ventricular function is normal. In summary, there is insufficient 
documentation to support the medical necessity for removal of the dual-chamber defibrillator and replacement 
with a bi-ventricular pacemaker. 
 
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 upgrade to a biventricular pacemaker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an upgrade to a biventricular pacemaker.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT code 
78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 PET scan. Our physician reviewer 
found the enrollee has had subjective complaints of memory problems for more than six (6) months. However, 
the records provided for review did not readily support that the enrollee has met diagnostic criteria either let 
alone both AD and FTD. The enrollee is not confirmed to have a formal form of dementia as there were 
functional/psedodementia in the differential diagnoses. Given these factors the request would ultimately not 
meet the NCD requirements for coverage at this time. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging, PET; metabolic evaluation (CPT code 78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for back pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas neoGen-series therapy Vasopneumatic device 
therapy (97016), injection (96732), and associated codes for the subcutaneous injection of FDA Nutri-
Pharmaceutical blend. 
 
You asked the Plan to pay for the Sanexas neoGen-series therapy Vasopneumatic device therapy (97016), 
injection (96732), and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. 
You say that the services are medically necessary. The Plan denied your request. The Plan says this service is 
experimental. 
 
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 pay for the Sanexas neoGen-series therapy 
Vasopneumatic device therapy (97016), injection (96732), and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the use of electrostimulation/ 
electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic 
diseases, is insufficient to warrant coverage. These procedures are considered investigational and are not 
eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying 
systemic diseases. Regarding vasopneumatic devices may be considered medically necessary for the 
application of pressure to an extremity for the purpose of reducing edema. The Non-PAR provider utilized the 
vasopneumatic device for chronic pain. The records do not reflect treatment of edema. This does not meet 
guidance for coverage. Regarding the subcutaneous injection of FDA Nutri-Pharmaceutical blend, the clinical 
value and effectiveness of the FDA Nutri-Pharmaceutical blend in the setting of chronic pain and multiple 
sclerosis have not been demonstrated in the peer-reviewed literature. 
 
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 Sanexas neoGen-series therapy Vasopneumatic device therapy (97016), 
injection (96732), and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend 
have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-series 
therapy Vasopneumatic device therapy (97016), injection (96732), and associated codes for the subcutaneous 
injection of FDA Nutri-Pharmaceutical blend.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 5, 
2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were interested in 
receiving treatment but were told that treatment was unavailable. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 an urgent care visit.  
 
The record shows that the emergency relief COVID-19 cost share waiver expired on September 30, 2021. The 
record also shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$50 copayment for an urgent care visit. An urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on October 5, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from February 17, 
2021, to February 28, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has provided insufficient information to support their denial 
of payment for the SNF services. The Plan provided no evidence to support their reasoning for denial of 
payment based on Medicare criteria. It is the Plans responsibility to provide supporting documentation and 
Medicare guidelines used to show the denial of payment is correct. Therefore, we decided that the Plan has to 
pay for the skilled nursing facility (SNF) care provided from February 17, 2021, to February 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (64483). 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements 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 epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the patient's work-up 
does not appear complete and it does not appear to have radiculopathy. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection (64483).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 the 
services are medically necessary. Our physician reviewer found based on the clinical information present it is 
both clinically reasonable and necessary to provide daily skilled nursing services on an in-patient basis due to 
the frequent wound care needs and close medical monitoring of blood pressure. The enrollee will also benefit 
from skilled therapy services on a more frequent and in-patient basis that would be provided in an skilled 
nursing facility to improve the enrollee's condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nonemergency transport taxi. 
 
You asked the Plan to pre-approve the nonemergency transport taxi. You say that you have vision problems 
that do not allow you to drive and that you need your transportation for your dialysis. The Plan denied your 
request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  
 You have already exhausted the established benefit. Your 2022 EOC states the Plan covers thirty-six (36) one-
way trips per year for medical appointments in any medical facility and picking up prescriptions in pharmacies. 
Method of transportation includes but is not limited to taxi, bus, van, or other available methods of 
transportation, such as an automobile through a contracted provider. Therefore, we decided that the Plan does 
not have to pre-approve the nonemergency transport taxi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; other 
peripheral nerve or branch (CPT code 64450). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has tried multiple conservative 
measures and the enrollee does not want to do a knee replacement. The Plan denied your request. The Plan says 
these health plans also consider this procedure to be experimental and investigational due to a lack of scientific 
evidence regarding the effectiveness of a genicular nerve block for the knee. 
 
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 this is considered an experimental/ investigational procedure whose role in the management of 
knee osteoarthritis is still being evaluated. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (CPT code 
64450).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined 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 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office Visit provided on October 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office Visit. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Office Visit provided on October 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you believe your services should be 
covered. The Plan denied your request. The Plan says you have been charged the correct coinsurance amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay $496.08, which is 20% of the allowed amount for the injection. The allowed 
amount is $2,480.40 (20% x $2,480.40 = $496.08). The injection falls within the Medicare Part B prescription 
drugs 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 injection provided on 
January 3, 2022.