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

 
We decided that the Plan does not have to pre-approve a crown (D2740), core buildup, including any pins 
when required (D2950), and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the crown, core buildup, and endodontic therapy. You say that you are 
currently experiencing sensitivity and pain to percussion. You also say that you understand the Plan's decision, 
and are wondering if there is another way that you can receive help. The Plan denied your request. The Plan 
says these services are not covered under 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, 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 (D2740), core buildup, including any pins when required (D2950), and endodontic therapy (D3310).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a detailed picture study is not supported because it would not show the doctor all of the 
details needed for treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found CMS guidelines specify 
that PET scan of the brain is not covered unless there is a differential of AD vs. FTD and that is not the issue in 
this case per the submitted records. Likewise, the enrollee exhibits typical signs of PD including tremors of the 
type usually seen in PD. CMS specifies that PET will not be covered for other causes of cognitive disorders or 
CNS degenerative processes. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a PET scan for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the cervical spine. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says a CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the records do 
not show a recent trial and failure of conservative measures for neck pain, including physical therapy. There are 
no red flags for a CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics for the enrollee. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are necessary for the enrollee. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you need these services to treat your 
scoliosis. The Plan denied your request. The Plan says the records do not show you have a subluxation. 
 
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.  
 
We looked at the file and Medicare rules. The submitted medical records do not document the presence of a 
subluxation with an x-ray or physical exam. Based on this information, we decided that Medicare rules for 
coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-
approve chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dynamic Neural Retraining System to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve Dynamic Neural Retraining System. You say that the online program, while 
not in network, consists of a well-known and widely recognized therapeutic model called CBT. The Plan 
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. 
This provider is not eligible to participate in Medicare. 
 
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. If you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Dynamic Neural Retraining System to be provided by an out of network (OON) provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's nursing, medical management, and rehabilitation needs 
do not require an interdisciplinary team approach to delivery of rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion Vertiflex interspinous spacer. 
 
You asked the Plan to pre-approve a Superion Vertiflex interspinous spacer. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 Superion Vertiflex interspinous 
spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found under consideration is a request for the Superion Vertiflex 
interspinous spacer at the L3/4 and L4/5 levels. Current evidence based medical guideline and peer reviewed 
literature do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the safety 
and effectiveness of this device for this enrollee's medical condition. FDA indications include implantation of 
the Superion device at one or two adjacent lumbar levels for moderate spinal stenosis in patients in whom 
operative treatment is indicated at no more than two levels, from L1 to L5, and for patients that experience 
relief in flexion from symptoms of leg/buttock/groin pain. These indications have not been met as there is 
documented severe spinal stenosis at the L4/5 level, and moderate neuroforaminal narrowing at all levels from 
L2-S1. Additionally, pain is reported to be worse with forward flexion. FDA contraindications include 
osteoporosis, and this has not been adequately addressed in the medical records. There is imaging evidence of 
diffuse osteopenia. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in 
this 66-year-old male. Superion indirect lumbar decompression would not be considered the standard of care 
for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically 
reasonable and necessary for treatment of this enrollee's medical 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 a Superion Vertiflex interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Superion Vertiflex interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair (K0824). 
 
You asked the Plan to pay for a power wheelchair. You say that this was medically necessary. The Plan denied 
your request. The Plan says you did not have an evaluation for the power mobility device that meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are covered only when 
all of the above listed 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 pay for a power wheelchair. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the documentation does not indicate 
a face-to-face encounter with a detailed gait evaluation, neuromuscular evaluation of the upper and lower 
extremities took place. The note did not clearly indicate that a major reason for the visit was a mobility 
encounter. The documentation does not indicate you have a personal mobility deficit that specifically impairs 
participation in MRADLs in the home. There is no detailed medical progress note by a treating medical 
practitioner with a detailed upper and lower extremity neuromuscular exam indicating why your mobility 
deficit is unable to be  helped by a cane, manual wheelchair, or walker. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pay for a power wheelchair (K0824).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 2, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that lab testing 
generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific 
medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on 
January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received 
on February 24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were only a 
passenger in the ambulance. The Plan denied your request. The Plan says you were charged this cost sharing 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each ambulance trip. You had 1 ambulance trip during which you received medical care. The 
Plan charged you $250 for these services. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services (A0429) received on February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 10, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because the hospital could not treat you so you had to be transferred to another hospital. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on May 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on May 14, 2020. 
 
You asked the Plan to pay for the crown. You say that the provider recommended that the crown to be replaced 
because you are afraid of gum disease. You also say that the provider's office asked if you pay a premium, and 
you understood that the service was covered. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. The Plan also says that you added the dental rider after this service was 
rendered. 
 
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. The crown (D2740) is only covered if you were enrolled in a Plan at the time of service. The records show that you enrolled the Plan effective 
June 01, 2020. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on 
May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the 
enrollee from April 6, 2020 through April 13, 2020. 
 
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that there was no imminent danger to self or 
others, command auditory hallucinations, cognitive impairment, or severe dysfunction in daily living that 
required 24-hour professional observation in an inpatient setting. 
 
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 the inpatient psychiatric hospital services. 
Our reviewer says that the inpatient psychiatric hospital services were not medically reasonable and necessary 
for the enrollee in this case. This enrollee did not appear to require inpatient mental health treatment as she was 
not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not 
appear that active treatment was taking place. It did not appear that the services were reasonably expected to 
improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's 
condition did not meet Medicare criteria for inpatient psychiatric hospital services. 
 
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 inpatient psychiatric hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the 
enrollee from April 6, 2020 through April 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D0330) and problem focused limited 
oral evaluation (D0140) provided on May 4, 2020. 
 
You asked the Plan to pay for the endodontic therapy and problem focused limited oral evaluation. You say 
that these procedures should have been covered as part of the crown coverage. The Plan denied your request. 
The Plan says endodontic therapy is not a covered benefit under your dental plan. The Plan also says that the 
problem focused limited oral evaluation 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, endodontic therapy is not among those 
covered under this benefit. The contract clearly states that problem focused limited oral evaluations (D0140) 
are limited to one procedure per plan year. The record shows that you received a problem focused limited oral 
evaluation (D0140) on January 7, 2020 and your problem focused limited oral evaluation (D0140) benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D0330) 
and problem focused limited oral evaluation (D0140) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminectomy (63047 and 63048) provided on March 2, 
2020. 
 
You asked the Plan to pay for the laminectomy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 laminectomy. Our reviewer says that CPT codes 63047 
and 63048 do not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 63047 and 
63048 were submitted to the health plan with an 80 modifier, indicating these services were performed by an 
assistant surgeon.  The medical records submitted indicate that the provider billing 63047 80 and 63048 80 is a 
physician assistant (PA),which would be represented by an AS modifier, therefore, inappropriate use of 
modifier 80 has been used with 63047 and 63048 and these charges, as billed, are not eligible for 
reimbursement consideration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laminectomy have not been met. Therefore, we decided that the Plan does 
not have to pay for the laminectomy (63047 and 63048) provided on March 2, 2020.