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

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint lateral branch block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. 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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no documentation on physical examination of three (3) or more positive tests 
results.  The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature.  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.  
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sacroiliac (SI) joint lateral branch block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
February 3, 2023. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) provided on February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on March 12, 2022, billed with 
codes 93010, and 93010-76. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says these services are duplicates of a previously paid 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 imaging services provided have 
been met. Specifically, complete medical records for services provided on March 12, 2022, have not been 
provided for review. Therefore, we decided that the Plan does not have to pay for imaging services provided on 
March 12, 2022, billed with codes 93010, and 93010-76.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture treatments (97810) provided from June 17, 2022, 
through August 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services are not payable as they were 
rendered by an ineligible provider. 
 
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. Specifically, the Plan has stated that the acupuncture treatments provided are not 
payable as they were rendered by an ineligible provider. However, the Plan contract states that supplemental 
coverage is provided for chronic low back pain in addition to the relief of musculoskeletal pain conditions. 
Covered services must be performed by a licensed acupuncturist. You received treatment for chronic low back 
pain including, hand pain, and knee pain from a licensed acupuncturist. Therefore, you meet criteria for 
coverage of these services under the supplemental benefit policy. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the acupuncture 
treatments (97810) provided from June 17, 2022, through August 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2021, 
through October 4, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on September 27, 2021 with increased 
shortness of beath and tachycardia. She was found to be Covid positive. She was treated with increased 
supplemental oxygen, intravenous antibiotics (Cefepime), and intravenous steroids. Her white blood cell count 
was elevated to 21T and her brain natriuretic peptide (ProBNP) level was elevated to 2200. She was admitted. 
Her condition stabilized and improved with medical therapy and she was discharged October 4, 2021 when 
considered medically stable. The review indicates the record showed that at the time of the inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 27, 2021, through October 4, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service December 
22, 2022. 
 You asked the Plan to pay for procedure code 76857. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76857 is bundled into payment for code 
76856. 
 
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, we have confirmed that code 76857 
is a column II code to column I code 76856. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76857 billed for date of service December 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fitbit purchased on December 13, 2022. 
 
You asked the Plan to pay for the Fitbit. You say that you were told by the Plan that the Fitbit model you were 
buying was okay. You state when your Health Plan was changed over in 2022, the Plan did not change your 
wellbeing benefits on the website until 2023. The Plan denied your request. The Plan says you earned 30 points 
out of 200 allowed per calendar year. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the Fitbit have not been met. Review of the file shows that you 
only earned 30 points out of 200. Your 2022 EOC states that the Plan will provide a Healthyroads Prepaid 
Gift Card(s) for completing certain preventive health services and wellness activities. The program is designed 
to help you maintain a healthy lifestyle. 1 point earned is equivalent to $1 earned. Points may be earned and 
redeemed online at mvphealthcare.com or via phone through Healthyroads in 50 point / $50 increments with 
a $200 maximum redemption per calendar year. Points can only be converted to plan-specified retailor gift 
cards. No partial point redemptions allowed. Therefore, we decided that the Plan does not have to pay for the 
Fitbit purchased on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on December 12, 2022, from an 
out-of-network provider.  
You asked the Plan to pay for the eyeglasses. You say that this should be covered. The Plan denied your 
request. The Plan says this is not covered when an out-of-network provider is used. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses purchased on December 12, 2022, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00320 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 00320. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 00320 is bundled into payment for code 31500. 
 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, we have confirmed that code 00320 
is a column II code to column I code 31500 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 00320 billed for date of service September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 8, 2023. Therefore, 
we decided that the Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment provided on February 3, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the enrollee has exhausted the allowable 
benefit for the service provided in this case.  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture service have not been met. Specifically, the acupuncture service in this case was not rendered 
on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not have to pay 
for the acupuncture treatment provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound-guided radiation therapy. You say that ultrasound-guided 
radiation therapy is a medical necessity for the enrollee. The Plan denied your request. The Plan says 
ultrasound-guided radiation therapy is experimental/investigational for the enrollee's condition. 
 
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 ultrasound-guided radiation therapy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that usually image-guided radiation therapy is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to the enrollee for which the target lesion can be seen on the skin to assist in daily set up. To bill for daily simple simulations and/or image-guided radiation therapy for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general) is not necessary. Daily ultrasound-guided radiation therapy would not 
be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound-guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 Reader. 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 
the FreeStyle Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 Reader.
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 to receive additional intense rehabilitation 
therapy in order to regain strength and to be able to go home. The Plan denied your request. The Plan says you 
do not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 22, 2022, billed 
with code 78815-26-PI. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the service provided was billed with an invalid 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes that may be used.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This service was billed with diagnosis code 
C50.911, which is not listed as an appropriate code for procedure code 78815. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on November 22, 2022, billed with code 78815-26-PI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
facet joint injections (64493, 64494) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 3, 2021. 
Therefore, we decided that the Plan does not have to pre-approve partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D4263), biologic materials to 
aid in soft and osseous tissue regeneration (D4265) and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft (D4263), biologic materials to aid in soft and osseous tissue regeneration (D4265) and gingival irrigation (D4921).