Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 2, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you are aware this service is 
only covered once every three years, but you only lacked 6 months being the three year period. The Plan denied 
your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on February 27, 2018, and your comprehensive oral evaluation 
(D0150) has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #9 (D2750). 
 
You asked the Plan to pre-approve a crown on tooth #9. You say that you need this because you are feeling 
pain and discomfort. The Plan denied your request. The Plan says the frequency limitation for this service has 
been exceeded. 
 
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, the requested service is covered only 
once every five years. The record shows that you previously received a crown on tooth #9 on March 15, 2017. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #9 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulation trial for the enrollee. 
 
You asked the Plan to pre-approve a spinal cord stimulation trial. You say that this should be covered by the 
Plan. The Plan denied your request. The Plan says the member has had a 2 trials of spinal cord stimulator 
insertion in 2018 and in 2019 which were unsuccessful for pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that the A/B MAC will reimburse for placement of a 
maximum of two leads or sixteen contacts, and for two spinal cord stimulator (SCS) trials per anatomic spinal 
region per patient per lifetime. 
 
We looked at the file and Medicare rules. The file indicates the enrollee has already had two spinal cord 
stimulator trials. Based on this information, we decided that Medicare rules for coverage of a spinal cord 
stimulation trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal 
cord stimulation trial for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration 
because the compression stockings help your condition and are the only treatment. The Plan denied your 
request. The Plan says compression stockings are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided July 31, 2020. 
 
You asked the Plan to pay for routine ECG with at least 12-leads. You say that please see attached medical 
records and reprocess for payment procedure code 93010 as this is a payable procedure code. The Plan denied 
your request. The Plan says this service is considered as a bundled service with the emergency department visit 
that was billed on the same date of service by another provider within the same specialty group. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the billing of code 93010 was 
submitted inappropriately due to the bundled relationship of services within the specialty group. This service is 
already included in the emergency department evaluation and management payment. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided 
July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided July 20, 2020 to August 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as they were in 
the past. The Plan denied your request. The Plan says the benefit was 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, the allowance for dental services is 
limited to $500 a year. The record shows that the $500 was expended on three previously paid claims. The 
benefit was exhausted at the time these services were obtained. Therefore, we decided that the Plan does not 
have to pay for dental services provided July 20, 2020 to August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 14, 2020, through 
July 16, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care 
provided was medically necessary for the enrollee. The Plan denied your request. The Plan says that the 
inpatient hospital care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was admitted with significant anemia on anti-coagulation therapy. It 
is reasonable that the physician expected the necessary hospital care to span at least two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from July 14, 2020, through July 16, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because you 
have severe rheumatoid arthritis and foot orthotics are a better option than surgery. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #28. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says crowns are not covered under any condition. 
 
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, 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 a 
crown for tooth #28.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on September 25, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says you did not request prior authorization. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the physician services provided on September 25, 2020 by an out of network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided May 20, 
2020. 
 
You asked the Plan to pay for the x-ray services. You say that records attached supporting multiple procedures 
rendered on this date. Please reprocess charge for separate reimbursement. The Plan denied your request. The 
Plan says CPT code 71045 is a column II procedure to the column I procedure 32555. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the billing of code 71045 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day Based on Medicare billing guidelines, this claim cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, 
we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided May 20, 
2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Imfinzi, carboplatin, etoposide, dexamethasone, palonosetron, and 
pegfilgrastim. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 medically necessary. Our physician reviewer found the enrollee has extensive stage small cell 
lung cancer and gastrointestinal primary small cell carcinoma of the liver. The combination of 
carboplatin/etoposide with Imfinzi (durvalumab) is FDA approved for the treatment of extensive stage small 
cell lung cancer. Small cell cancers are all treated as small cell lung cancer. The service is reasonable and 
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 been met. Therefore, we decided that the Plan has to pre-
approve Imfinzi, carboplatin, etoposide, dexamethasone, palonosetron, and pegfilgrastim.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an intra-thecal injection of fentanyl prior to pump placement. 
You asked the Plan to pre-approve the fentanyl injection. You say that it is felt that this trial should be allowed 
to assess for placement of a pain pump. The Plan denied your request. The Plan says that a single injection is 
not supported in this case as a catheter should be placed to adequately assess the results.  
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
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 fentanyl injection. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a female with chronic abdominal pain with numerous episodes of pancreatitis. 
She is on high dose oral and transdermal opiate therapy. The request is for a trial of intra-thecal fentanyl. The 
Plan's denial rationale is that a catheter must be placed and that only an FDA-approved intra-thecal medication 
can be used. 
It is entirely within the standard of care to perform an intra-thecal opiate trial with Fentanyl. Clinical practice 
guidelines support this approach. As such, this treatment is considered 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 fentanyl injection have been met. Therefore, we decided that the Plan has to 
pre-approve an intra-thecal injection of fentanyl prior to pump placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown on tooth #30. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says any service that are provided over the frequency limit are not covered. 
 
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. The Plan covers crowns once 
every five years. 
 
A crown for tooth #30 was received on August 20, 2019. Therefore, you would be eligible for this service 
again on August 20, 2024. Based on this information, we decided that the Plan's rules for coverage of the 
crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental crown on 
tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ventilator.
You asked the Plan to pre-approve the ventilator. You say that you would like the claim to be paid. The Plan
denied your request. The Plan says the respiratory assist device is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the enrollee does have chronic respiratory
failure related to COPD. Although the medical record supports the use of adding on ventilation technology, a
full mechanical home ventilator was not supported as there was no trial and failure of a BiPAP machine with
AVAPS ventilation technology for breathing support which would work sufficiently for this patient's needs
based on the provided records. Therefore, this request will be considered not medically necessary for this
patient 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 a ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a non-invasive ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 31, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on October 23, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 pathology services provided on October 23, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the planned procedure listed under CPT code 63047 is not listed on the 
CMS Inpatient Only List.  The Plan states the procedure is currently approved as an ambulatory procedure and 
there is no documentation provided to support the expectation the enrollee will require a greater than two (2) 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. If the enrollee experiences any 
peri- or post-operative complications, reconsideration for inpatient level of care can be performed on 
concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-
approve inpatient hospital care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colorectal services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you are unable to care for yourself. The Plan 
denied your request. The Plan says services are available with an in-network provider. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve colorectal 
services to be provided by an out of network (OON) provider.