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

 
We decided that the Plan does not have to pre-approve the intraosseous nerve ablation (64628, 64629) 
 
You asked the Plan to pre-approve the intraosseous nerve ablation. You say that  the denial letter says the 
procedure would be performed on your knee. You say the procedure would be done on your back and your 
doctor agrees that the services are necessary for his condition. The Plan denied your request. The Plan says the 
physical exam and radiologic studies show additional significant pathologies that are unlikely to benefit from 
the procedure and is not approved. 
 
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 intraosseous nerve ablation. Our 
reviewer says that the intraosseous nerve ablation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation is not evident regarding which level(s) are being requested for the procedure. In this case, there were/are multiple plausible pathologic sources of 
significant pain generation. 
 
The documentation does not show reasonably detailed or evidenced findings supportive of the spinal vertebral 
bodies as being the overwhelming primary generators of your chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation, in 
this case, 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 
Medicare rules for coverage of the intraosseous nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the intraosseous nerve ablation (64628, 64629)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray, a veneer, and fillings. 
 
You asked the Plan to pay for panoramic x-ray, a veneer, and fillings. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
panoramic x-ray, a veneer, and fillings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable, folding, heavy-duty power wheelchair for 
community use. 
 
You asked the Plan to pre-approve a portable, folding, heavy-duty power wheelchair for community use. You 
say that you need this item to go grocery shopping and for community use. The Plan denied your request. The 
Plan says this item is not covered when its primary use is for outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable, folding, heavy-duty power wheelchair for community use.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the provider knows your medical history. The 
Plan denied your request. The Plan says there are in-network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 28, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastectomy (19307). 
 
You asked the Plan to pay for the mastectomy. You say that the service was medically necessary and should be 
covered. The Plan denied your request. The Plan says that both the provider and the taxonomy listed on the 
claim are not eligible to participate in Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the mastectomy (19307).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that the procedure will 
benefit the enrollee's lumbar stenosis with neurogenic claudication symptoms and findings on previous lumbar 
spinal magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the Vertiflex Superion 
Interspinous device to L3-L4 and L4-L5 is not medically necessary. Specifically, there is multi-level disease to 
L3-5 involving facet joints, lateral recesses and discs. Given the diffuse disease, the medical necessity of 
treatment of only L3-5 is not 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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, and 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 the Vertiflex Superion Interspinous device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown  porcelain/ceramic substrate (D2740) provided on 
February. 8, 2023. 
 
You asked the Plan to pay for a crown . You say that this should be covered. The Plan denied your request. The 
Plan says crowns are only covered in conjunction with a listed root canal 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown  
porcelain/ceramic substrate (D2740) provided on February. 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of tooth #21, #22, #27 and #28 
(D7210) and temporary complete upper and lower dentures (D5810 and D5811). 
 
You asked the Plan to pre-approve the surgical removal of teeth. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the plan must receive documentation showing that 
removal of bone and/or resectioning of the tooth is required. The plan received additional information from the 
treating provider's office which did not include this information. 
 
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 surgical 
removal of teeth 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 surgical removal of teeth. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the lower teeth are intact with 
full crowns and would not be expected to require any removal of bone to extract #21, 22, 27 and 28.  Surgical 
extractions require that it would be necessary to remove bone to effectuate removal of the tooth.  Where the 
tooth is essentially intact there would be no expectation of a need for cutting of bone to extract it.  In this 
instance, given the radiographic appearance of the involved teeth gives no indication of a need for any surgical 
intervention to remove them, and therefore no need for surgical extractions as requested. 
 
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 surgical removal of teeth and temporary complete upper and lower dentures 
have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical removal of tooth 
#21, #22, #27 and #28 (D7210) and temporary complete upper and lower dentures (D5810 and D5811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) at-home COVID-19 test kits 
(87426) and sales tax (S9999) purchased on February 16, 2023. 
 You asked the Plan to pay for the at-home COVID-19 test kits and sales tax. You say that you would like to be 
reimbursed for the at-home COVID-19 test kits you purchased. The Plan denied your request. The Plan says at-
home COVID-19 testing kits are not eligible for reimbursement by Medicare or Medicare Advantage plans. 
The Plan also says that sales tax is not covered by Medicare 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax. The rules also say that Medicare does not pay for OTC items and the at-home COVID-19 test kits and 
sales tax is an OTC item. The Plan does not offer a supplemental benefit covering this service. However, these 
could be obtained with participating providers and covered by Original Medicare when using your Medicare 
card rather than your Plan card. Therefore, we decided that the Plan does not have to pay for the over-the-
counter (OTC) at-home COVID-19 test kits (87426) and sales tax (S9999) purchased on February 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that physical and aqua therapy is the 
only thing that gives you 2-3 days of relief at one time, and you try to go 3 times a week so you can twist, turn 
and bend because of the nerve pain going down your legs. The Plan denied your request. The Plan says 
minimal progress has been made and does not support the need for continued/additional physical 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 physical 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 the records do not support continued therapy based on 
your prior response. Services needed can maintain at home with a repetitive 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be provided safely in other settings.  
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided on 
December 17, 2021 and November 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for the services provided in this case.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Additionally, the Plans contract states that routine 
chiropractic coverage provides maintenance manual manipulation of the spine. The Plans contract covers four 
routine chiropractic visits per calendar year.  
 
We reviewed the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of these services have not been met. Specifically, the Plans contract states that four routine 
chiropractic visits are covered per calendar year.   
 
 
The Plan previously issued payment for four routine chiropractic visits provided on October 27, 2022,  
March 15, 2022, May 26, 2022, and August 23, 2022. Therefore, you have exhausted the allowable benefit for 
the services provided in this case. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatments (98941) provided on December 17, 2021 and November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete maxillary denture (indirect)) (D5750) 
provided on March 30, 2020. 
 
You asked the Plan to pay for reline complete maxillary denture. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for reline 
complete maxillary denture (indirect)) (D5750) provided on March 30, 2020.
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 the enrollee meets criteria for admission 
to the LTACH, and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the records do not show that it is necessary for the enrollee to be in an LTACH in place 
of an acute care hospital. 
 
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 that the records indicate the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.   
 
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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services (99284, 72040, 73030) 
provided on March 8, 2023. 
 
You asked the Plan to pay for the ER services. You say that the services were medically necessary and should 
be covered. The Plan denied your request. The Plan says this is a freestanding ER and not Medicare certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Medicare covers services in an emergency department only if the 
emergency clinic is affiliated with a hospital. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services 
(99284, 72040, 73030) provided on March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0627) purchased on December 9, 
2022. through a non-participating provider. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the item should be covered. The Plan 
denied your request. The Plan says this item was purchased through a provider that in not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0627) 
purchased on December 9, 2022. through a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive physical and 
occupational therapy for strengthening. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care.  
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.