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

 
We decided that the Plan does not have to pay for chiropractic services (97010, 98941) provided on June 26, 
2023. 
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
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 to correct a subluxation. The 
diagnosis code billed is not a covered diagnosis per Local Coverage Article: Billing and Coding: Chiropractic 
Services (A56273). Therefore, we decided that the Plan does not have to pay for chiropractic services (97010, 
98941) provided on June 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this is medically necessary. 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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, involving only sentinel node biopsies and two negative lymph 
nodes, the risk of lymphedema is very low. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy (BIS) (93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to approve the 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 March 30, 2017. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
26, 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 January 18, 2023, and 
February 2, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on July 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with release of transverse 
carpal ligament (29848). 
 
You asked the Plan to pre-approve endoscopy, wrist, surgical, with release of transverse carpal ligament. You 
say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that 
you have had failed response to a four-week trial of splinting or failed response to local corticosteroid injection. 
 
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 endoscopy, wrist, surgical, with release 
of transverse carpal ligament. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial 
and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. There 
are no electrodiagnostic studies provided to corroborate pathology. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale 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 endoscopy, wrist, surgical, with release of transverse carpal ligament have not 
been met. Therefore, we decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with 
release of transverse carpal ligament (29848).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Specifically, the provider is located 61.5 
miles away from your residence. The Plan only covers distances up to 50 miles. 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 for routine transportation (A0170).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0425, A0427) provided on July 
7, 2023. 
 
You asked the Plan to pay for the ambulance transportation. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when a beneficiary is admitted to an Inpatient 
Hospital or Critical Access Hospital (CAH), it may be necessary to transport the beneficiary to another hospital 
or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original 
provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient 
hospital or CAH service. 
 We looked at the file and Medicare rules. The enrollee was an inpatient when this service was provided. Based 
on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0427) 
provided on July 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs from July 26, 2023, through July 27, 
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 self-administered drugs from 
July 26, 2023, through July 27, 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 drugs provided on July 31, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not understand why the 
payment is being denied. The Plan denied your request. The Plan says that self-administered drugs do not fall 
under Medicare Part B coverage. 
 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 
provided on July 31, 2023.  
 
Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. 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 the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for chronic pain. 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve blocks with fluoroscopic guidance. 
 
You asked the Plan to pre-approve peripheral nerve blocks. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve peripheral nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found peripheral nerve blocks for knee pain are experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve peripheral nerve blocks with fluoroscopic guidance.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 25, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing facility care provided on April 25, 2023.
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 the inpatient rehabilitation facility services would 
enhance the quality of the enrollee's life. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility services are not medically necessary.  
 
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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not met the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Alendronate, 
Risedronate and an injectable bisphosphonate before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show the enrollee has chronic compression fractures that occurred over 12 
weeks ago. 
 
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 does not meet criteria for coverage. Our physician reviewer found there is no imaging study showing 
an acute fracture less than 12 weeks old. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513, 22515).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 14, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were handled in-
network and should be paid. The Plan denied your request. The Plan says with the information provided, they 
could not determine if the enrollee received the service or if it was medically necessary. 
 
 
 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 the subsequent nursing facility care provided on 
June 14, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 28, 2023. 
 
You asked the Plan to pay for the self-administered drugs . You say that you have no idea what is being denied. 
You say that you believe the item in question has something to do with the heart scan you received. The Plan 
denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 
provided on July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve 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 pre-approve 
gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the requested procedure is medically necessary. 
The Plan denied your request. The Plan says the requested service is not medically necessary as it does not 
meet the LCD requirements for coverage. 
 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 repeat ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there is no documentation that the enrollee has had at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at 
least three (3) months. There is no documentation that the provider will be using a different medication or 
approach than the ESI that was done on October 2, 2023. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).