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

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that a sacroiliac joint injection is 
medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint injection does 
not meet the Medicare LCD coverage criteria.  
The Plan follows Medicare rules. 
 
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 sacroiliac joint injection. Our 
reviewer says that the requested sacroiliac joint injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case, there is no documentation on physical examination of 
tenderness of the SI joint and no mention of SI provocative testing being completed with positive findings.  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. The review has determined that the 
requested sacroiliac joint injection does not meet the Medicare 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 a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the service is not a covered benefit until its efficacy has 
been established. 
 
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 requested services. Our physician 
reviewer found Our physician reviewer found that the requested device is considered experimental. More 
research is needed to show its safety and efficacy. Therefore, the request is not medically necessary. 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you have a hard time walking and are 
homebound. You need a mobility scooter. The Plan denied your request. The Plan says records do not show 
that you or your caregiver are unable to use a manual wheelchair or that there is enough room in your home for 
the power wheelchair. You walk slowly but there is no information to show that you cannot accomplish your 
MRADLs entirely. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. There is no 
documentation to show your condition can be improved by a walker, cane, or manual wheelchair or that you 
cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle, 
group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 provided on September 12, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99291 is included in the global surgery 
payment for procedure code 32540 provided on September 9, 2022. Separate payment cannot be made for 
procedure code 99291. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99291 provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the dental cleaning (D1110) and the 
periodic oral evaluation (D0120) provided on January 9, 2023. 
 
You asked the Plan to issue additional payment for these dental services. You say that you are requesting a 
reconsideration of the Plan's denial for additional payment. The Plan denied your request. The Plan says your 
benefit for the services provided 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 services provided was exhausted on January 9, 2023.   
 
Specifically, the Plans contract states that you are reimbursed up to $150 every year for routine, preventive 
dental benefits. The Plan issued payment in the amount of $150 on January 31, 2023 for the dental services 
provided. Therefore, you have exhausted the allowable benefit for the services provided in this case. Therefore, 
we decided that the Plan does not have to issue additional payment for the dental cleaning (D1110) and the 
periodic oral evaluation (D0120) provided on January 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva Handihaler capsules. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is unable to use Spiriva Respimat 
as they cannot correctly twist the device. 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 Spiriva Handihaler 
capsules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Drive Nitro Duet Rollator and transport chair (E1399). 
 
You asked the Plan to pre-approve the Nitro tall rollator walker. You say that you need the walker to be able to 
walk long distances like when you go to church or the sore. The Plan denied your request. The Plan says the 
specific brand of rolling walker (E1399) described as a Drive Nitro Duet Rollator and transport chair does not 
meet the requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Nitro tall rollator walker have been 
met. the documentation does not support whether a walker or wheelchair will resolve the functional mobility 
needs in the home and why a specific brand of device is needed over a walker or a manual wheelchair with an 
approved Medicare code. The Plan made multiple attempts to obtain medical records without success. 
Therefore, we decided that the Plan does not have to pre-approve Drive Nitro Duet Rollator and transport chair 
(E1399).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovenous ablation therapy of incompetent vein of extremity 
(36475 or 36482) and injection of foam sclerosant (36465). 
 
You asked the Plan to pre-approve endovenous ablation therapy and sclerosant injection. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the 
requested services are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that invasive procedures for the treatment of varicose veins are 
considered medically reasonable and necessary when ALL of the criteria listed in the Medicare rules section of 
this letter have been met. 
 
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 endovenous ablation therapy and 
sclerosant injection. Our reviewer says that the requested services are medically reasonable and necessary in 
this case. Our physician reviewer found that the provided documentation meets all coverage criteria and 
supports the medical necessity of the treatments in question. There is documentation of satisfactory arterial 
perfusion to the lower extremities bilaterally and that the enrollee has a history of varicose bleed in the area of 
interest. This is an indication for treatment that does not require a period of conservative care. There is documentation of absence of deep vein thrombosis (DVT) and the presence of significant reflux in the 
saphenous vein to be treated. There is documentation of associated tributaries in the area of the varicose bleed 
manageable with sclerotherapy. You have provided CEAP and VCSS scores as requested. You note that there 
is no intention to perform both endovenous ablation therapy procedures (36475 and 36482). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy and sclerosant injection have been met. Therefore, 
we decided that the Plan has to pre-approve endovenous ablation therapy of incompetent vein of extremity 
(36475 or 36482) and injection of foam sclerosant (36465).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and wound care services (99499) to be 
provided by an out-of-network (OON) provider at an in-network benefit level. 
 
You asked the Plan to pre-approve office visits and wound care services. You say that you disagree with the 
denial. The Plan denied your request. The Plan says this service is available by a provider in the enrollee's 
network. However, if he chooses to receive services from this out of network provider, his share of the cost for 
his covered services may be higher. 
 
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. The enrollee has a PPO plan and can utilize 
their out of network benefits to see the requested provider. Therefore, we decided that the Plan does not have to 
pre-approve office visits and wound care services (99499) to be provided by an out-of-network (OON) provider 
at an in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheters provided on January 16, 2023, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for catheters. You say that similar claims were paid in the past. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 catheters provided on January 16, 2023, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that an Intracept procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says an 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that imaging studies show spondylolisthesis. The cause of the enrollee's back 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthesis with microprocessor foot 
feature. 
 
You asked the Plan to pre-approve a replacement prosthesis with microprocessor foot feature. You say that a 
replacement prosthesis with microprocessor foot feature is medically necessary The Plan denied your request. 
The Plan says the requested replacement prosthesis with microprocessor foot feature does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 replacement prosthesis with 
microprocessor foot feature. Our reviewer says that the requested replacement prosthesis with microprocessor 
foot feature is not considered medically necessary in this case. Our physician reviewer found that a replacement 
prosthesis with microprocessor foot feature was requested. However, although the enrollee appears to require a 
replacement prosthesis, it was not clear that they had failed a more basic prosthesis without a vacuum socket 
which the enrollee utilized in the past. The Medicare LCD criteria does not cover the L5988 code.  
 
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 replacement prosthesis with microprocessor foot feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis with microprocessor 
foot feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3334). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3334).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81266, 81265) provided on September 23, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was 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 the know error DNA Specimen Provenance 
Assay is a statutorily excluded test. 
 
We looked at the file and Medicare rules. The test performed is non-covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81266, 81265) provided on 
September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2022, to May 30, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2022, to May 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital care services (99223) provided on August 3, 2022. 
 
You asked the Plan to pay for hospital care services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial states that the inpatient services at issue have been 
billed with an inappropriate place-of-service (POS) code. The case record documents that the claim reports 
POS code 21, indicating inpatient services. Additionally, the Plan indicates that the services at issue cannot be 
paid separately. However, the Plan has not specified nor documented the more comprehensive services into 
which it alleges that hospital care services are to be bundled. It is the Plan's responsibility to support its denial 
rationale with evidence. In this case, the Plan's denial has not been supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for hospital care services (99223) provided on August 3, 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.