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

 
We decided that the Plan does not have to pre-approve destruction of nerve branches of knee using imaging 
guidance (64624). 
 
You asked the Plan to pre-approve destruction of nerve branches of knee using imaging guidance. You say that 
this is medically necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental or investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 destruction of nerve branches of knee 
using imaging guidance. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found limited published, large-scale, long-term 
peer-reviewed literature shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to corroborate this treatment modality is as safe and effective as other standard 
treatments for the bilateral knees. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction of nerve branches of knee using imaging guidance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction of nerve branches of knee 
using imaging guidance (64624).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit and x-ray of wrist (73110, 
99283) provided on August 27, 2023. 
 
You asked the Plan to pay for the ER visit and x-ray. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
rendering provider is not enrolled with 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 an emergency room (ER) visit and x-ray 
of wrist (73110, 99283) provided on August 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that the services are medically necessary for 
you to go to wound care. The Plan denied your request. The Plan says the additional mileage exceeds the Plans 
limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the one-way trip is up to 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on June 5, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that your doctor wanted to 
call the ambulance, but you did not need one. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray, a crown, a cone beam computed 
tomography (CT) image, pulp vitality tests, prefabricated post and core, intraorifice barrier, unspecified 
endodontic procedure, and consultation (D0220, D2740, D2954, D9310, D0460, D0380, D3999, D3911) 
provided on July 12, 2023, to July 25, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the intraoral x-rays and 
crowns has already been exhausted. Moreover, this benefit does not include cone beam computed tomography (CT) images, pulp vitality tests, prefabricated post and cores, intraorifice barriers, unspecified endodontic 
procedures, or consultations. 
 
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 intraoral x-rays and crown was exhausted on date of service July 6, 2023 (D0220) 
and July 21, 2023 (D2740). Moreover, this benefit does not include cone beam computed tomography (CT) 
images, pulp vitality tests, prefabricated post and cores, intraorifice barriers, unspecified endodontic 
procedures, or consultations. Therefore, we decided that the Plan does not have to pay more for an intraoral x-
ray, a crown, a cone beam computed tomography (CT) image, pulp vitality tests, prefabricated post and core, 
intraorifice barrier, unspecified endodontic procedure, and consultation (D0220, D2740, D2954, D9310, 
D0460, D0380, D3999, D3911) provided on July 12, 2023, to July 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from August 31, 2023, through 
September 6, 2023. 
 
You asked the Plan to pay for the medication. 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 pay for the self-administered drugs from 
August 31, 2023, through September 6, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided on August 11, 2023. 
 
You asked the Plan to pay for the medication. You say that you had multiple surgeries from an accident in 1987 
and are hoping to get amounts credited. 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 pay for the self-administered drug 
provided on August 11, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 24, 2023. 
 You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for anesthesia services provided on June 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis. 
 
You asked the Plan to pre-approve a lower limb prosthesis. You say that the requested item is necessary since 
you returned the socket you received previously. The Plan denied your request. The Plan says you received a 
new prosthesis in 2022 and in April 2023.  
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a lower limb prosthesis. A lower limb prosthesis serves the same purpose as the 
current lower limb prosthesis. Therefore, we decided that the Plan does not have to pre-approve a lower limb 
prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and related services provided on July 04, 2023, 
to July 25, 2023. 
 
You asked the Plan to pay for a home visit, and related services. You say that these services were 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 a home visit, and related 
services provided on July 04, 2023, to July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot and cold packs therapy provided by a chiropractor on 
September 6, 2023. 
 
You asked the Plan to pay for the hot and cold packs therapy. You say that the provider should have only done 
the manual manipulation. The Plan denied your request. The Plan says the only covered chiropractic service is 
manual manipulation of the spine. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the hot and cold packs therapy provided by a chiropractor on September 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and implant supported porcelain/ceramic 
crown (D6065, D0220) provided on August 10, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an intraoral x-ray and implant supported porcelain/ceramic crown (D6065, D0220) provided on 
August 10, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown repair necessitated by restorative material failure 
(D2980) provided on February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
repair necessitated by restorative material failure (D2980) provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on August 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 March 29, 2023, and July 
28, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation 
(D0180) provided on August 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Clarifix procedure (30117, 30801, 30469). 
 
You asked the Plan to pre-approve the Clarifix procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the Clarifix procedure is considered investigational as a treatment option for 
the enrollee's condition. 
 
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 Clarifix procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal congestion and a deviated nasal 
septum. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the 
requested service for 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 the Clarifix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Clarifix procedure (30117, 30801, 30469).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that after the procedure the enrollee was 
able to walk with their cane, carry a case of soda and lay with their leg straight with minimal pain. The Plan 
denied your request. The Plan says the genicular nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered experimental and investigational therapy. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit system (K0108) and pneumatic tires (E2211, 
E2213). 
 
You asked the Plan to pre-approve the transit system and pneumatic tires . You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items are for outdoor use and not primarily used 
in 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 the transit system (K0108) and pneumatic tires (E2211, E2213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter basket (E1399). 
 
You asked the Plan to pre-approve a scooter basket. You say that you need this item. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a scooter basket (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral radiofrequency ablation at the L3-L4, L4-
L5 and L5-S1 levels. 
 
  You asked the Plan to pre-approve the bilateral radiofrequency ablation. You say that you have been treated 
with pain medications and physical therapy with no relief. You say that every sudden movement affects you 
because of the pain.  The Plan denied your request. The Plan says the bilateral radiofrequency ablation is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bilateral radiofrequency ablation. 
Our reviewer says that the bilateral radiofrequency ablation is not medically necessary. Our physician reviewer 
found that you have not had two sets of diagnostic medical branch blocks providing at least 80% pain relief on 
each side. Also, only two levels may be treated with bilateral radiofrequency ablations at each session. 
Therefore, the request is not medically reasonable and 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 bilateral radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the bilateral radiofrequency ablation at the L3-L4, L4-L5 and L5-S1 
levels.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request is not medically necessary because the records show the enrollee does 
not have osteoporosis and subsequently the enrollee does not have an osteoporotic vertebral compression 
fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 kyphoplasty. Our reviewer says that the 
enrollee meets criteria for coverage. Our physician reviewer found the enrollee has tried conservative therapy 
including analgesics and local therapy, but the symptoms persist. The amount of vertebral body loss in height is 
50% which is well above the cutoff of 25% required for the procedure. The enrollee has tried conservative 
measures and has increasing pain. L2 compression fracture with increasing pain and 50% loss in height of 
vertebral body are valid indications for the requested procedure. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have been met. Therefore, we decided that the Plan has to pre-
approve kyphoplasty.  
 
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.