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

 
We decided that the Plan does not have to pre-approve office visits (99203, 99213) for pain management to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must receive care from a network provider. 
There are in-network providers available for this service. 
 
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 
office visits (99203, 99213) for pain management 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 high dose-rate electronic brachytherapy (skin surface). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that brachytherapy is less expensive and 
can get better cosmetic and functional outcomes. 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are insufficient long-term efficacy and safety data to support the routine use of 
electronic surface brachytherapy for treatment of the enrollee's condition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high dose-rate electronic brachytherapy (skin surface).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve dentures. You say that you are not eating and are having abdominal pain. 
You say you had a very bad experience at the dentist's office and would like to get reinstated for new dentures. 
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 July 15, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty (22511).  
 
You asked the Plan to pre-approve a percutaneous vertebroplasty. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PVP is covered when all the criteria listed in the 
Medicare rules section are 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 percutaneous vertebroplasty. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that there is no trial of 
fracture bracing. More conservative measures are 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 a percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebroplasty (22511).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on February 2, 2023, billed with procedure 
code 71045-26. 
 
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 that the claim was not billed with the required 
modifier. 
 
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. We find that the specific denial rational offered by the plan is not supported. The 
plan states that the patient status listed on the claim indicates that the patient was in custody when the services 
were provided and are not payable unless billed with a valid modifier. The plan has not provided actual 
evidence that the enrollee was listed in custody on the date the services were provided. Therefore, we decided 
that the Plan has to pay for imaging services provided on February 2, 2023, billed with procedure code 71045-
26.  
 
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 pay for physical therapy, vasopneumatic devices and vitamin 
injections provided on March 1, 2023.  
 
You asked the Plan to pay for physical therapy, vasopneumatic devices and vitamin injections. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the requested physical therapy, 
vasopneumatic devices and vitamin injections are 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 pay for physical therapy, vasopneumatic devices and vitamin injections. Our reviewer says that the requested physical therapy, vasopneumatic devices and vitamin 
injections are not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the recommended treatment plan with physical therapy, vasopneumatic devices and vitamin injections is 
not standard of care for this enrollees medical condition and is not medically appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy, vasopneumatic devices and vitamin injections have not been 
met. Therefore, we decided that the Plan does not have to pay for physical therapy, vasopneumatic devices and 
vitamin injections provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bioimpedence spectroscopy device (93702).  
 
You asked the Plan to pre-approve the Bioimpedence device. You say that you believe the use of ImpediMed's 
L-Dex device is medically necessary. The Plan denied your request. The Plan says this device is unproven. 
There are not enough medical studies that show safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Bioimpedence device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Bioimpedence spectroscopy device (93702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three home physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that additional physical therapy is medically 
necessary for your balance. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that there are 
no medical notes from your treating physician documenting an order or need for additional skilled therapy 
services. Further utilization of a home exercise program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three home physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), double upright, thigh and calf, 
with adjustable flexion and extension joint (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you are requesting reconsideration because the 
medical unloader knee brace may help the enrollee. The Plan denied your request. The Plan says the request is 
not medically necessary because the records show the enrollee does not have a recent injury or surgery to her 
knee or documentation which shows knee instability. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that on July 3, 2023, a medical progress note indicates the enrollee has had right knee steroid 
injections without long-term relief for her right knee pain. On exam, she has tenderness of the right knee, varus 
alignment, swelling, reduced range of motion. X-rays show bone on bone changes of the right knee without 
fracture. Per documentation, the enrollee is ambulatory with a walker. The documentation does not reveal 
evidence of objective joint laxity or instability on a physical examination. There is no evidence of a recent 
injury or surgery to the knees. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension 
joint (L1852).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IGSRT. 
 
You asked the Plan to pre-approve IGSRT. You say that IGSRT is covered by Medicare Part B.  The Plan 
denied your request. The Plan says IGRST 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 IGSRT. Our reviewer says that the 
requested IGSRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of basal cell carcinoma of the right nasal sidewall. Based on the medical 
records provided and the guidelines of the National Comprehensive Cancer Network (NCCN) there is no 
documentation that support that the Image-Guided Superficial Radiotherapy (IGSRT) at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee per Social Security Act, Section 1862(a)1(A). The NCCN Guidelines Version 1.2023 Basal Cell Skin Cancer do not support IGSRT for 
treatment of basal cell skin carcinoma.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGSRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGSRT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel median nerve neuroplasty (64721). 
 
You asked the Plan to pre-approve carpal tunnel median nerve neuroplasty. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not tried conservative conventional 
treatment. 
 
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 carpal tunnel median nerve neuroplasty. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the submitted records do not include detailed documentation regarding a 
trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 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 carpal tunnel median nerve neuroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve carpal tunnel median nerve neuroplasty (64721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you have had multiple injections, 
acupuncture, and three rounds of physical therapy with little relief. You say that surgery is not an option, and 
the denial of radiofrequency ablation should be changed. The Plan denied your request. The Plan says 
radiofrequency ablation of the sacroiliac joint is not considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint denervation (also called 
Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not require skilled services. Home health aides are not available when skilled services are 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a dentist. 
 
You asked the Plan to pre-approve the dental service. You say that you need the dental work to be covered 
under your medical plan due to your teeth problems being cause by chemotherapy. The Plan denied your 
request. The Plan says dental services are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an office visit (99205) 
with a dentist.
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 November 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
billable and payable. 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 
November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you do not meet criteria for approval of a 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode which 
is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).