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

 
We decided that the Plan does not have to pre-approve arthrodesis (22612), and posterior non-segmental 
instrumentation (22840). 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says there are not enough studies on Minuteman procedure to show it is 
safe and effective. Therefore, it is not considered standard of care. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone 
graft material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature 
for (existing or potential intraoperative) instability have not been documented and/or met in this case. In 
addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical 
condition that have not been fully documented as having been excluded and/or ruled out. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis (22612), and posterior non-segmental instrumentation (22840).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve quantitative calcium scoring.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the set up portable x-ray equipment (Q0092), the 
transportation of portable x-ray equipment (R0075) and the chest x-ray (70146) provided on March 22, 2023, 
by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the set up portable x-ray equipment (Q0092), the transportation of portable x-ray 
equipment (R0075) and the chest x-ray (70146). You say that the provider is the only one that can see the 
enrollee. The Plan denied your request. The Plan says  the set up portable x-ray equipment (Q0092), the 
transportation of portable x-ray equipment (R0075) and the chest x-ray (70146) is available in 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the set up portable x-ray equipment (Q0092), the 
transportation of portable x-ray equipment (R0075) and the chest x-ray (70146) provided on March 22, 2023, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284, 12011) provided on April 
24, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will not pay for services rendered to 
incarcerated members unless certain criteria defined in 42 CFR 411.4 (b) is met. Providers that render services 
or items to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate 
this fact on the claim by append a HCPCS modifier QJ on all lines with a line item date of service during the 
incarceration period. 
 
We looked at the file and Medicare rules. The records show the enrollee was incarcerated at the time the 
service was provided. The enrollee did not use the required QJ modifier. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided 
that the Plan does not have to pay for emergency room services (99284, 12011) provided on April 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73590-LT and 93005 billed for date of service June 
13, 2023. 
 
You asked the Plan to pay for codes 73590-LT and 93005. You say that these are payable codes. The Plan 
denied your request. The Plan says these codes are not paid separately. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning that they are STV-packaged services.  These disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 73590-LT and 93005 have not been met. Therefore, we decided that the Plan does not have 
to pay for codes 73590-LT and 93005 billed for date of service June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance, when performed. 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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance, when performed. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve block is experimental for knee 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 injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance, when performed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including 
imaging guidance, when performed (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nalu peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Nalu PNS. 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 Nalu PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the NALU PNS device is experimental for chronic pain. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Nalu PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Nalu peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x4). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 31, 2023. Therefore, 
we decided that the Plan does not have to pre-approve gingival irrigation (D4921 x4).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve REPATHA SURECLICK. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve REPATHA SURECLICK.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for these services. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture - complete mandibular (D5865). 
 
You asked the Plan to pre-approve overdenture - complete mandibular. You say that the dentures are no longer 
fitting, and it needs to be replaced. The Plan denied your request. The Plan says the criteria for overdenture- 
complete mandibular (D5865) has not been met and remains denied because this is an incorrect procedure 
code. 
 
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 overdenture - 
complete mandibular 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 overdenture - complete mandibular. Our reviewer says that the service is not medically necessary. Our physician reviewer found an overdenture 
D5865 would not be appropriate as the enrollee does not have any natural remaining. D6111 is a more 
reasonable and medically necessary procedure to aid in restoring the enrollees dentition and function, and this 
type of lower denture is supported by the implants the enrollee already has in his mouth. The enrollees 
provider should submit a new claim with the proper procedure code. D5865 is not medically reasonable or 
necessary. 
 
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 overdenture - complete mandibular have not been met. Therefore, we decided 
that the Plan does not have to pre-approve overdenture - complete mandibular (D5865).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. The Plan denied your request. The Plan says your 
range of motion, strength, and function are normal and can continue to perform home exercise program to 
maintain gains from therapy.  
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 additional progress with strengthening and controlling your pain can 
be accomplished in the context of a home exercise program and 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 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. 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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has chronic knee pain after knee 
arthroplasty. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of 
the requested service. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from JULY 01, 2023, through JULY 12, 2023. 
 
You asked the Plan to pay for the IRF care. You say that inpatient rehab is medically necessary. The Plan 
denied your request. The Plan says inpatient rehab was 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 pay for the 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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
medical problems are stable. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary 
care can be provided in a different level of care. 
There is not a reasonable expectation that this patient 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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from JULY 01, 
2023, through JULY 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on December 19, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the therapy treatments were medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the out-of-network services 
provided were not urgent or emergent, nor approved in advance. 
 
 
 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 the physical therapy services provided on 
December 19, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has made significant 
improvements throughout treatment but has not been able to return to performing household chores and daily 
activities without restrictions. You say the requested physical therapy is necessary as the enrollee continues to 
demonstrate difficulty with stair ambulation and ambulation in the community The Plan denied your request. 
The Plan says additional physical therapy visits 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 that the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The records 
do not demonstrate that the unique skills of a professional therapist are required to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under 
the supervision of a therapist. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The 
enrollee has had instruction in a home exercise program. The enrollee has had extensive prior physical therapy 
for this condition and does not require ongoing skilled therapy over a transition to an independent home 
exercise program. 
 
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 12 physical therapy visits.