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

 
We decided that the Plan does not have to pre-approve genicular nerve blocks/injections/radiofrequency 
ablation (64624) and genicular nerve injections (64454 x2). 
 
You asked the Plan to pre-approve genicular nerve blocks/injections/radiofrequency ablation and genicular 
nerve injections. You say that the enrollee has severe degenerative changes to both knees, and is in severe pain 
constantly. You also say that apart from pain medication and the genicular nerve blocks with progression to 
radiofrequency neurotomy (RFN), you do not have many other options for analgesia. The Plan denied your 
request. The Plan says genicular nerve blocks and genicular nerve ablation are considered investigational and 
not medically necessary for the treatment of chronic knee pain. 
 
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 genicular nerve 
blocks/injections/radiofrequency ablation and genicular nerve injections. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and 
not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks/injections/radiofrequency ablation and genicular nerve 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve 
blocks/injections/radiofrequency ablation (64624) and genicular nerve injections (64454 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary for you to regain your 
strength and be able to walk. The Plan denied your request. The Plan says the requested IRF services are not 
medically necessary. 
 
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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you nay have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the technetium tc-99m medronate 
injection for imaging provided on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the technetium tc-99m medronate injection for imaging. You 
say that you met your maximum out-of-pocket. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 surgical supplies, including chemical agents used in certain diagnostic procedures. 
 
You have been asked to pay 20% coinsurance for the technetium tc-99m medronate injection for imaging. This 
item/service falls within the surgical supplies, including chemical agents used in certain diagnostic procedures 
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 technetium tc-99m 
medronate injection for imaging provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that you are requesting a CGM for the enrollee 
because they have a hard time handling small strips used in conventional testing monitors. Also, they are 
having fluctuating sugar levels. The Plan denied your request. The Plan says the enrollee does not require 
insulin three or more times daily. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the denial. The Plan 
denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the SSBCI benefits have been met. 
Medical records were requested, but not received. Therefore, we decided that the Plan does not have to pre-
approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in a hospital and need an IRF because you 
cannot walk or use the bathroom alone. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be provided safely in other settings. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acupuncture services provided on 
November 03, 2022. 
 
You asked the Plan to waive the copayment for acupuncture services. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 acupuncture services. 
 
You have been asked to pay a $15 copayment for acupuncture services. This item/service falls within the 
acupuncture 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 acupuncture services 
provided on November 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says because the Plan's 
criteria have not been met and it has not demonstrated that it is medically necessary to make an exception for 
the enrollee, this request is not approved. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
enrollee does not meet the coverage criteria for Evenity. Our physician reviewer found there is indication that 
the enrollee has tried and failed Fosamax but there is no indication that the enrollee has tried and failed either 
zoledronic acid or Prolia. Our reviewer also found that there is no indication that either zoledronic acid or 
Prolia would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) provided on September 27, 
2022. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you would like this claim to be reprocessed 
because it is for durable medical equipment (DME)) that is covered by Medicare, and meets the criteria for 
coverage. The Plan denied your request. The Plan says the explanation of benefits (EOB) from the primary 
carrier is needed before payment reconsideration. 
 
  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the explanation of benefits (EOB) from the primary carrier. As the secondary insurer, the Plan cannot be held 
responsible for the ankle foot orthosis until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1971) provided on 
September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you do meet the criteria because you have 
diabetes. The Plan denied your request. The Plan says there is no documentation that all the criteria has been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the SSBCI benefits have been met. 
Medical records were requested, but not received. Therefore, we decided that the Plan does not have to pre-
approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
testing of 6-11 targets (87632, 87634, 87541) provided on August 25, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR 
panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel testing of 6-11 targets (87632, 87634, 87541) provided on August 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic labratory testing provided on August 24, 2022. 
 
You asked the Plan to pay for genetic labratory testing. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic labratory testing 
provided on August 24, 2022.
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 the rehabilitation services in order to 
recover. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs 
can be met at a lower level of care such as a skilled nursing facility, home with home health services, or home 
with outpatient therapy. 
 
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 were admitted for infection of the lower leg and had a below the knee 
amputation and was evaluated for possible infection of right hip joint. Your medical problems are stable, and 
there are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances for the resin-based composites - two 
surfaces, anterior (D2331) provided on January 7, 2022, and June 6, 2022. We decided the Plan does not have 
to pay for the resin-based composite - three surfaces, anterior (D2332) and the limited oral evaluation - 
problem focused (D0140) provided on January 7, 2022. We also decided the Plan does not have to pay for an 
intraoral - periapical first radiographic image (D0220) and the limited oral evaluation - problem focused 
(D0140) provided on June 6, 2022. 
 
You asked the Plan to waive the coinsurance for dental code D2331. You also asked the Plan to pay for the 
dental services represented by D0140, D2332, and D0220. You say that your injuries were not evident at the 
time of your fall. You also say that months later you had a tooth come loose due to the previous fracture. The 
Plan denied your request. The Plan says the coinsurance was appropriately applied to the dental services 
represented by D2331. The Plan says that dental services represented by codes D0140 and D0220 are not 
covered under the enrollees benefits. The Plan says that the dental services represented by code D2332 are not 
covered because the benefit for resin-based composites has been exhausted.  
 
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 55% 
coinsurance for resin-based composites provided out-of-network. 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. 
 
You have been asked to pay a 55% coinsurance for dental service represented by D2331. This service falls 
within the Restorations (Fillings) Amalgam and/or Composite provided out-of-network 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 coinsurances for the resin-based composites - two surfaces, anterior 
(D2331) provided on January 7, 2022, and June 6, 2022.  
 
The record shows you received coverage for 2 composite procedure codes in the 2022 calendar year. This 
exhausted your benefit for resin-based composites. Therefore, we decided that the Plan does not have to pay for 
the resin-based composite - two surfaces, anterior (D2332) provided on January 7, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services represented by 
codes D0140 and D0220 are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for limited oral evaluation - problem focused (D0140), and intraoral - periapical first 
radiographic image (D0220) provided on January 7, 2022 and June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection provided on October 20, 2022. 
 
You asked the Plan to pay for infectious agent detection. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for infectious agent 
detection provided on October 20, 2022.