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

 
We decided that the Plan does not have to pay for the medical nutrition therapy services you received on 
January 9, 2023. 
 
You asked the Plan to pay for the medical nutrition therapy services. You say that your doctor recommended 
these services because you have a gastrointestinal condition. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan 
does not have to pay for the medical nutrition therapy services you received on January 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency facet ablations (64635, 64636). 
 
You asked the Plan to pre-approve repeat radiofrequency facet ablations. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. The enrollee has had two previous radiofrequency ablations within 
the past 12 months. Based on this information, we decided that Medicare rules for coverage of repeat 
radiofrequency facet ablations have not been met. Therefore, we decided that the Plan does not have to pre-
approve repeat radiofrequency facet ablations (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutmentsincludes placement for 
teeth number 5, 14, 30 (D6057 x 3), abutment supported porcelain/ceramic crowns for teeth number 14, 30 
(D6058 x 2), and an abutment supported retainer for a porcelain/ceramic fixed partial denture for tooth  
number 5 (D6068). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has 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 items has been exhausted. Specifically, the Plans contract provides 
coverage for two dental implants per year. The Plan previously authorized dental implants for teeth number 2 
and 4. Additionally, the Plan authorized a porcelain/ceramic pontic for tooth number 3. Therefore, you have 
exhausted the allowable benefit for the requested items at this time. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutmentsincludes placement for teeth number 5, 14, 30  
(D6057 x 3), abutment supported porcelain/ceramic crowns for teeth number 14, 30 (D6058 x 2), and an 
abutment supported retainer for a porcelain/ceramic fixed partial denture for tooth number 5 (D6068).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar kyphoplasty surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found magnetic resonance imaging (MRI) and 
x-ray of your lumbar spine show that you have an acute compression fracture at the L2 level. There is no 
detailed documentation of a trial and failure of recent reasonable, comprehensive, and less-invasive 
conservative care measures. The records do not support that the criteria for coverage are met and the surgery is 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar kyphoplasty surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
October 5, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that these should be covered 
100%. The Plan denied your request. The Plan says the cost sharing will be applied according to the Plan 
contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $45 copayment for each specialist office visit.  

The enrollee has been asked to pay a $45 copayment for the specialist office visit. This item/service falls within 
the physician/practitioner services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit provided on October 5, 2022.
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 an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid 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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that you have chronic low back pain and sciatica. You had conservative therapy 
trials without improvement. You have had multiple epidural steroid injections every three months. Physical 
exam indicates positive straight leg raising test. Imaging showed foraminal stenosis. You received 
transforaminal epidural steroid injection in January 2023. However, there is no documentation of the degree 
and duration of the pain relief achieved. The lack of documentation does not support the approval of this 
injection. It is not medically reasonable and necessary, at this time, due to a lack of documentation. 
 
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 epidural steroid 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 an office visit with a tertiary level of care 
endocrinologist. 
 
You asked the Plan to pre-approve an office visit with a tertiary level of care endocrinologist. You say that an 
office visit with a tertiary level of care endocrinologist is medically necessary. The Plan denied your request. 
The Plan says you do not meet the rules to see a tertiary care endocrinologist and the services can be received 
with a lower level of care community provider. 
 
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 office visit with a tertiary level of 
care endocrinologist. Our reviewer says that the requested office visit with a tertiary level of care 
endocrinologist is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no convincing reason given why you could not see an in-network endocrinologist for 
evaluation. You have not failed an in-network evaluation. An endocrinologist in-network should be able to 
evaluate for hypothyroidism and possible adrenal/hormonal issues. 
 
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 office visit with a tertiary level of care endocrinologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an office visit with a tertiary level of care 
endocrinologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) described by code 
K0861 and accessories. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a PWC and accessories are covered when specific 
criteria 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee is non-ambulatory and has 
Parkinson's disease. He does not have a high risk for skin breakdown nor spasticity or use of a catheter. He 
does not require an expandable controller or alternative means of controlling the wheelchair, as the records 
support his upper body strength is adequate to use the standard controls. The criteria for coverage are not met; 
therefore, the Group 3 PWC with multiple power options and requested accessories is not medically necessary 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) described by code K0861 and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the NanoKnife (49203). 
 
You asked the Plan to pre-approve the NanoKnife. You say that you are appealing the denial of CPT 49203. 
The Plan denied your request. The Plan says The clinical value, effectiveness, and safety of irreversible 
electroporation (IRE) including use of the NanoKnife for tissue ablation in the setting of pancreatic cancer not 
been demonstrated in the peer-reviewed literature. 
 
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 NanoKnife. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has locally advanced pancreatic cancer status post chemotherapy and has plans for 
undergoing surgery in the hospital. However, the provided documentation and currently available literature 
does not sufficiently support NanoKnife (tissue ablation) efficacy and safety compared to other treatment 
methods for this enrollee's condition (pancreatic cancer) to meet coverage criteria. Therefore, this request for 
NanoKnife will be considered not medically necessary 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 NanoKnife have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the NanoKnife (49203).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on December 1, 2022.  
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service 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 Plan's 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 service provided was exhausted on date of service October 3, 2022. Specifically, the 
Plan's contract states that one limited oral evaluation is covered every year. You previously received this 
service on October 3, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-
problem focused (D0140) provided on December 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic exam of the bladder and urethra you had on 
December 5, 2022. 
 
You asked the Plan to pay for the diagnostic exam. You say that you have been seeing this provider for a while 
and these services were covered in March of 2022.  You believe that these services should be covered again. 
The Plan denied your request. The Plan says the provider of these services opted out of Medicare effective 
April 1, 2022, so these services cannot be paid. At the time of the services in March 2022, the provider had not 
yet opted out of Medicare, which is why that claim paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
diagnostic exam of the bladder and urethra you had on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
October 5, 2022, through October 13, 2022 and November 9, 2022, through November 30, 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 the acute inpatient psychiatric hospital care 
provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the progress notes do not indicate that the enrollee had been aggressive with peers or staff on the unit or 
has had any recent attempt to harm himself during the dates in question. He was medically cleared for  
discharge and was awaiting long-term placement. There was no indication in the available medical records that 
the enrollees psychiatric symptoms could not be managed on a less restrictive basis. He was noted to have 
confusion at his baseline mental status. The enrollee was not exhibiting any other significant symptoms such as 
psychosis with intent to harm himself or others or mania. He had no acute psychiatric issues that would require 
continued inpatient care. The enrollee has chronic symptoms. The available medical records do not support that 
inpatient care would have changed these symptoms or the enrollees current condition. The enrollee is 
chronically impaired due to cognitive impairment and the inpatient hospital stay was not expected to improve 
the enrollees condition in a reasonable period of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from October 5, 2022, through  
October 13, 2022 and November 9, 2022, through November 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 29, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 29, 2022, to April 
27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81503) provided on January 20, 2023, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network laboratory services. You say that these services were referred by 
the enrollee's treating physician. The Plan denied your request. The Plan says these services were not provided 
or referred by a contracted/in-network provider. Out-of-network services are only covered in certain limited 
circumstances which have not been met in this case. 
 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 laboratory services (81503) provided on January 
20, 2023, by an out-of-network (OON) provider.
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 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 the request does not meet the Medicare LCD criteria since you have other 
significant pain generators. 
 
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.