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

 
We decided that the Plan does not have to pre-approve implantation of carotid sinus baroreflex activation 
device. 
 
You asked the Plan to pre-approve implantation of carotid sinus baroreflex activation device. You say that it is 
medically necessary. The Plan denied your request. The Plan says this is considered investigational or 
experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implantation of carotid sinus baroreflex 
activation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found Baroreflex stimulation devices have been considered 
potential alternative treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid 
sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the 
baroreceptors of one of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved 
the system for use in patients with refractory heart failure who remain symptomatic despite treatment with 
guideline-directed medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not 
candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal 
daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains 
an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the 
value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in this enrollees clinical 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 implantation of carotid sinus baroreflex activation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve implantation of carotid sinus baroreflex 
activation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3347 x2), 
the post removal (D2955), the intraorifice barrier (D3911 x2), the incomplete endodontic therapy (D3332), the 
prefabricated post and core (D2954 x2), the abutment crown (D6740 x2), and the porcelain/ceramic pontic 
(D6245) provided by August 16, 2023, to August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have already paid $761 to the provider.  
You say according to your dental plan, your total out of pocket responsibility is $117.75. The Plan denied your 
request. The Plan says the services are not covered benefits. 
  
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of 
previous root canal therapy (D3347 x2), the post removal (D2955), the intraorifice barrier (D3911 x2), the 
incomplete endodontic therapy (D3332), the prefabricated post and core (D2954 x2), the abutment crown 
(D6740 x2), and the porcelain/ceramic pontic (D6245) provided by August 16, 2023, to August 22, 2023. 
  
Your complaint about your dentist providing a refund is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a history of diabetes and 
fatigue. The last physical exam revealed short stride length and wide base of support. Neuro exam was 
negative. Request for MRI cervical spine has been denied absent any red flag or neurological finding related to 
upper extremities. No conservative measures including physical therapy are noted. Cervical spine films showed 
degenerative changes, but there is no neurological referral. 
 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be managed at the current facility until they 
are more stable for transfer to another level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services that would be offered at the LTACH that are not available at the 
current setting. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that there is no 
documentation of when the prior epidural steroid injection was done with documentation of at least 50% 
improvement in pain for at least three months. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits (99214) and assessments (G0463),  to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visits and assessments . You say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrolllee must use network providers. 
 
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 
the office visits (99214) and assessments (G0463),  to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nutritional therapy to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the nutritional therapy. You say that you are requesting reconsideration of 
the denied services. The Plan denied your request. The Plan says the services were not approved. 
 
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 
the nutritional therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure. 
 
You asked the Plan to pre-approve intracept procedure. You say that it is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental and investigational because of insufficient evidence 
of their effectiveness for these indications. 
 
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 intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found There is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service July 6, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was necessary to direct treatment 
plans. The Plan denied your request. The Plan says that the test is not an approved test. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. 
 
The file shows that an MI Tumor Seek Hybrid test was provided. We looked at the file and Medicare rules. The 
MolDX program has determined that this test is a covered benefit. Based on this information, we decided that 
Medicare rules for coverage of the billed testing have been met. Therefore, we decided that the Plan has to pay 
for the lab testing billed for date of service July 6, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve You asked the Plan to pre-approve transurethral waterjet 
ablation of the prostate. 
 You asked the Plan to pre-approve You asked the Plan to pre-approve transurethral waterjet ablation of the 
prostate. You say that Medicare guidelines and the medical records provided support the request for the 
procedure in dispute. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
treatment for enlarged prostate with an intense jet of water does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that treatment for LUTS/BPH treatment will be 
considered reasonable and necessary when performed once in patients with a maximum urinary flow rate of 
less than or equal to 15 mL/s4. Medicare rules also say that 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has mild bladder outlet obstruction with a maximum flow rate of 
17ml/sec. 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 transurethral waterjet ablation of prostate. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve You asked the Plan to pre-approve transurethral waterjet 
ablation of the prostate.
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 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 Intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease, and 
the cause of pain is not clear. Therefore, the coverage criteria have not been met. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's continued care needs include continued 
intravenous antibiotics, wound care, weekly monitoring of labs, and therapy to get stronger. The Plan says 
services may be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require LTACH level of care services can be managed at a 
skilled nursing facility.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary.  Our physician reviewer found that the enrollee has 
thoracic radiculopathy and has tried physical therapy. Also, the enrollee has tired medications such as 
gabapentin, Aleve, Ibuprofen and Tylenol. Therefore, the enrollee meets all of the LCD coverage criteria. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve Zilretta. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the information provided does not meet the requirements for coverage. 
 
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 Zilretta. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of 
Dexamethasone injection and Triamcinolone injection before they will approve the requested drug. In this case, 
the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plan's required drugs would likely be less effective or likely have adverse effects for the enrollee. The request 
for Zilretta cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
25, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees generally must receive their care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care provided on September 25, 2023, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says LTACH was denied as not meeting criteria, not medically necessary, and 
continued acute hospital stay was offered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is receiving appropriate care in current acute care setting as provided by 
Health Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.