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

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider.  
 
You asked the Plan to pre-approve SNF care to be provided by an OON provider. You say that the enrollee is 
not able to go home and needs physical therapy and occupational therapy. The Plan denied your request. The 
Plan says the service can be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an OON provider.
Appeal type: Surgery
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  the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the Intracept procedure is 
not medically necessary. The Plan says the enrollee's spinal bones were connected with a prior surgery and the 
same place the procedure is planned. The medical studies do not show that this procedure works well when this 
is the case. 
 
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 service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has already had spinal fusion surgery with lumbar fusion. The intracept procedure is experimental when used in cases of previous fusion 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that a second medial branch block was performed. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD requires 2 sets of diagnostic blocks and each must produce 80% pain relief. 
The request is not medically reasonable and necessary since one set has not been performed yet. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy sessions. 
 
You asked the Plan to pre-approve the therapy services. You say that 10 additional physical therapy sessions 
are medically necessary. The Plan denied your request. The Plan says 10 additional physical therapy sessions 
are not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you are independent with daily activities and mobility and require 
some assistance with the use of your upper extremities when transferring from a seated to standing position. 
You have mild deficits in knee range of motion and nearly normal motor strength. You can further improve 
your function and range of motion with a home exercise program, and this does not require the services of a 
skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy sessions.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 1, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were not aware that 
the services would not be covered. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 21, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the ambulance was 
called due to passing out and transportation to the hospital was declined. The Plan denied your request. The 
Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and related services 
provided on June 15, 2023, to June 22, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that the enrollee 
was in a nursing home setting at the time services were rendered. 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 subsequent nursing 
facility care, and related services provided on June 15, 2023, to June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request 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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental 
therapy. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the genicular nerves.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the Barostim Neo device is considered unproven and 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 a Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of the Barostim Neo device in patient management. 
  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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0856) and accessories (E1002, 
E2361, E2603, K0040, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if u se of a power 
wheelchair will significantly improve the beneficiarys ability to participate in mobility-related activities of 
daily living and the beneficiary will use it in the home and the beneficiary has the mental and physical 
capabilities to safely operate the power wheelchair that is provided or, if the beneficiary is unable to safely 
operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally 
configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is 
provided. 
 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 power wheelchair and accessories. 
Our reviewer says that the criteria for coverage of the requested power wheelchair have not been met. Our 
physician reviewer found there is not evidence a person with dementia can safely operate a power wheelchair 
or that the power wheelchair will assist the enrollee with self-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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0856) and accessories (E1002, E2361, E2603, 
K0040, K0108).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 4, 2023. 
 You asked the Plan to pay for the ambulance services. You say that hospice is not responsible for the transport. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on June 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device. 
 
You asked the Plan to pre-approve the Coflex lumbar interspinous decompression device. You say that the 
enrollee is at risk of being wheelchair bound. The Plan denied your request. The Plan says the requested device 
is unproven and not medically necessary due to insufficient evidence of efficacy. 
 
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 Coflex lumbar interspinous 
decompression device. 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. 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 Coflex lumbar interspinous decompression device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Coflex lumbar interspinous 
decompression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft - retained natural tooth - first 
site in quadrant for teeth #28, 29, and 30 (D4263), guided tissue regeneration - resorbable barrier, per site 
(D4266), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230 x3). 
 
You asked the Plan to pre-approve bone replacement graft, bone replacement graft, and inhalation of nitrous 
oxide/analgesia. 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. 
 
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 certain dental 
procedures when the services are medically necessary and reasonable.  
 
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 bone replacement graft, bone 
replacement graft, and inhalation of nitrous oxide/analgesia. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the x-ray shows that implants #28,29, and 30 are 
connected. There is no bone or little bone around implant #28. There is severe bone loss, with minimal 
remaining bone around implant #30. Implant #29 has severe bone loss in the area adjacent to implant #29. 
These implants have a poor prognosis due to the amount of bone loss. There is minimal bone around the 
implant to hold bone graft material. Per the American Dental association D4266 can be used for areas of defect 
around an implant. D4263 is a dental procedure code that is associated with a natural tooth, and this code is not 
appropriate to be used for a bone graft around an implant. Due to the poor prognosis of these implants, bone 
grafts and resorbable barriers are not recommended. The oral surgeon documented in his notes the severe bone 
loss around the implants and had discussed removal of the implants. Due to the large amount of bone missing 
around the implants, D4266 and D4263 are not medically reasonable or necessary on implants that have a poor 
prognosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of bone replacement graft, bone replacement graft, and inhalation of nitrous 
oxide/analgesia have not been met. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft - retained natural tooth - first site in quadrant for teeth #28, 29, and 30 (D4263), guided tissue 
regeneration - resorbable barrier, per site (D4266), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230 
x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 14, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the doctor would have been grandfathered into the 
network when added to the group credentialing. The Plan denied your request. The Plan says the provider was 
out-of-network. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on October 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy visits provided from September 22, 
2022, to March 16, 2023. 
 
You asked the Plan to pay for the physical therapy visits. You say that you needed physical therapy while you 
were away, so it should be covered. The Plan denied your request. The Plan says this provider was out-of-
network and were not urgent/emergent in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered under limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency and urgent care services. Urgently needed services are defined as those needed 
because of an unforeseen illness or condition and it is not reasonable to get the services from the Plan.  
 
We looked at the file, Medicare rules, the Plans rules. These services do not fall within any of Medicares 
specified circumstances for coverage of services outside of the United States. Additionally, these services do 
not meet the Plans rules for coverage because they were not emergent or urgent in nature. Therefore, we 
decided that the Plan does not have to pay for the physical therapy visits provided from Ecuador from 
September 22, 2022, to March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93000, 96360-59, 96361-59, 96374-59, 
and 96375-59 billed for date of service July 18, 2023. 
 
You asked the Plan to pay for procedure code(s) 93000, 96360-59, 96361-59, 96374-59, and 96375-59. You 
say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says these 
codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 5 for CPT code(s) 96360-59, 96361-59, 
96374-59, and 96375-59, and there is a Professional/Technical indicator of 4 for CPT code 93000. This means 
that these codes are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 93000, 96360-59, 96361-59, 96374-59, and 96375-59 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 93000, 96360-59, 96361-59, 
96374-59, and 96375-59 billed for date of service July 18, 2023.