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

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
and an extraction (D7210) of tooth #4. 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation and extraction. You say 
that the enrollee needs an extraction of tooth #4 because the tooth is non-restorable due to decay. The Plan 
denied your request. The Plan says bone replacement graft for ridge preservation is not a covered benefit. The 
Plan also says that the extraction of tooth #4 does not meet the medical necessity criteria to support the service. 
 
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 the bone 
replacement graft for ridge preservation and extraction when the services are medically necessary and 
reasonable.  
 
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 extraction. Our reviewer says that 
the extraction (D7210) is not medically necessary. Our physician reviewer found the requested extraction code 
of D7210 is reserved for situations that require removal of bone in order to achieve removal of the tooth.  Our 
reviewer found that given the presentation of considerable bone loss (50%) along with the periapical infection 
that has caused loss of apical bone, there is no rationale for anticipating the need for a surgical procedure to 
remove tooth #4. Our physician reviewer also found that a simple extraction would be contemplated given the 
situation. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Though the Plan offers a dental benefit in 
excess of Medicare coverage, bone replacement graft for ridge preservation is not among those covered under 
this benefit. Based on this information, we decided that the Plan's rules for coverage of the bone replacement 
graft for ridge preservation and extraction have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone replacement graft for ridge preservation (D7953) and an extraction (D7210) of 
tooth #4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (RACZ 
procedure). 
 
You asked the Plan to pre-approve RACZ procedure. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this procedure is 
experimental/investigational. 
 
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 RACZ procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational 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 RACZ procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous lysis of epidural adhesions (RACZ procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that previous injections provided 70% 
improvement in pain, therefore the enrollee does meet the Medicare criteria. The Plan denied your request. The 
Plan says the denial of authorization for this service is correct, because previous procedures have not provided 
adequate pain relief. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions and thermal radiofrequency 
ablation are covered when the enrollee meets the clinical criteria 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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found in this case, 2 prior lumbar medial branch blocks yielded less than 80% pain relief and there 
was no record of functional gains or of at least 3 months of pain relief 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown and periodontal scaling and root planing. 
 
You asked the Plan to pre-approve the crown and periodontal scaling and root planing. You say that a regular 
prophylaxis will not resolve the periodontal disease. You say that tooth #4 needs full coverage. The Plan denied 
your request. The Plan says the criteria for coverage has not been met. 
 
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 the crown and 
periodontal scaling and root planing when the services are medically necessary and reasonable.  
 
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 crown and periodontal scaling and 
root planing. Our physician reviewer found that a normal restoration could be used to restore the tooth to 
normal function. Our physician reviewer found no subgingival calculus or bone loss in the left quadrants. Our 
reviewer says that the criteria for coverage has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown and periodontal scaling and root planing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the crown and periodontal scaling and root 
planing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 21, 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 this testing should be coded with CPT 81479. 
 
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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 21, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient residential addiction program with an out of network provider. You asked the Plan to pre-approve the inpatient residential addiction program with an out of network provider. You say that the services are medically necessary and the enrollee was sent to you by a network provider. The Plan denied your request. The Plan says that clinical support services are available with providers who are in network. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided us with the names of specific in network providers who are able to supply the same level of care being requested. The Plan has not addressed the appellant claim that an in network provider referred the enrollee to the current facility. Despite attempts to obtain additional information from the Plan, they have not submitted documentation to support their denial. The Plan has not provided evidence that adequate care is available within their network to treat the enrollee's condition. Therefore, we decided that the Plan has to pre-approve an inpatient residential addiction program with an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
lower right, lower left, upper right, and upper left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
x-rays do not show that the enrollee has noticeable bone loss or show that there is a hard substance built up on 
the root of the tooth. 
 
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 the scalings 
and planings when the services are medically necessary and reasonable.  
 
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 scalings and planings. Our reviewer 
says that the services do not meet the Plan's coverage criteria. Our physician reviewer found there are only 
three teeth charted in the upper right quadrant, making a request under code D4341 improper as this code is to 
be used for four or more teeth in a quadrant. Our reviewer found that the radiographs that were provided do not 
show any appreciable bone loss in four or more teeth in any of the remaining quadrants.  As scaling and root 
planing can only be performed where there are exposed root surfaces from bone loss, without that loss of bone 
the requested procedure cannot be performed. Our physician reviewer also found that there is not four or more 
involved teeth (with noted bone loss) in any quadrant, and there is no medical necessity for the scalings 
(D4341). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the lower right, lower left, 
upper right, and upper left quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on August 21, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 35355 is not supported. 
 
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 CPT Code Manual definition of code 35355 is thromboendarterectomy, including patch graft, 
if performed; iliofemoral. 
 
We find that CPT code 35355 is not supported in the medical record. Specifically, the operative report contains 
documentation of a common femoral endarterectomy and there is a more appropriate code for these services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on July 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not in a Medicare-approved study, which is looking at the benefits of this 
device. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. The device should still be considered 
experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fourth sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the maximum allowable injections are three in a twelve-month period. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request exceeds accepted levels of chronic intra-articular steroid usage. More than three injections in 
a 12-month period carries the risk of steroid associated side-effects. The request therefore is considered not 
medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a fourth sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from March 17, 2020 at 12:06pm through March 19, 2020.
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization care. Our physician reviewer found the review indicates that all inpatient care provided after 12:05 pm on March 17, 2020 through 12:35 pm on March 19, 2020 was not needed on an emergent basis. There was no documentation provided necessitating post-stabilization care services at the non-participating facility after 12:05 pm on March 17, 2020. The post-stabilization care services March 17, 2020 at 12:06pm through March 19, 2020 were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from March 17, 2020 at 12:06pm through March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says you have been using a Freestyle Libre since June 2019, and the clinical notes do not 
supply any clinical information that would necessitate a change. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have type II diabetes, for which you use both oral and injectable medications. You are 
noted to use a long-acting insulin once a day. While you reportedly have a CGM, there is no evidence that you 
use the results of multiple times per day blood glucose checks to self adjust multiple times per day insulin 
administration. As such, the use of a CGM is not shown to be medically necessary or reasonable. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tuberculosis screening test provided on August 28, 2019. 
 
You asked the Plan to pay for the tuberculosis screening test. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tuberculosis screening test at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the tuberculosis screening test provided on August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI provided on February 1, 2020. 
 
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says that the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 did not pre-approve MRI. 
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 an MRI provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
February 21, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on February 21, 2020.