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

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer remains experimental. More research is needed to show safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 and 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Infliximab (J1745). 
 
You asked the Plan to pre-approve Infliximab. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Infliximab. Our reviewer says that 
Infliximab is not medically necessary. Our physician reviewer found the records clearly document past trial and 
failure of infliximab. There is no justification to re-try infliximab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infliximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infliximab (J1745).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the problem focused limited oral evaluation (D0140) 
provided on August 18, 2020. 
 
You asked the Plan to pre-approve the problem focused limited oral evaluation. You say that the services you 
received were medically necessary. The Plan denied your request. The Plan says the claim processed correctly 
to your liability. 
 
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 problem 
focused limited oral evaluation once every year.  
 
We looked at the file and Medicare rules. The file indicates that you received emergency diagnostic services in 
July 2020 which exhausted your benefit for 2020. Based on this information, we decided that the Plan's rules 
for coverage of the problem focused limited oral evaluation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the problem focused limited oral evaluation (D0140) provided on August 18, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three-phase bone scan (78315). 
 
You asked the Plan to pre-approve a three-phase bone scan. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not indicated. 
 
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 three-phase bone scan. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence based medical literature and guidelines would not typically support 
a three-phase bone scan as the next step for imaging. There is no clear suspicion documented in the medical 
records regarding malignancy relative to signs/symptoms, past medical history, family history, abnormal lab 
testing, or radiologist recommendation for additional study. 
 
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 three-phase bone scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a three-phase bone scan (78315).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110, a complete lower 
denture (D5120), and a simple extraction (D7140). 
 
You asked the Plan to pre-approve the dentures and simple extraction. You say that you are in tremendous pain 
all of the time. You say that your teeth are crumbling in your mouth. You say that you have lost 2 more teeth 
since you called to inquire about the denial that you received. You also say that your health conditions and 
medications are causing your teeth to become very brittle. The Plan denied your request. The Plan says 
dentures are not listed as covered dental items. The Plan says that simple extractions are not listed as a covered 
service either. 
 
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 
complete upper denture (D5110, a complete lower denture (D5120), and a simple extraction (D7140).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Polysomnography. 
 
You asked the Plan to pre-approve Polysomnography; age 6 years or older, sleep staging with 4 or more 
additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel 
ventilation, attended by a technologist (95811). You say that the enrollee needs Polysomnography. The Plan 
denied your request. The Plan says the enrollee does not have lung failure, heart failure, seizures or other health 
problems to qualify. 
 
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 Polysomnography (95811). Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found an attended PAP titration study is considered not medically necessary. The 
records indicate that the reason for requesting an attended titration study is the hypoxemia, so that oxygen can 
be titrated.  The enrollee has no respiratory disease, and the resting awake O2 saturations are normal, so the 
nocturnal hypoxemia is likely related to obstructive sleep apnea. The denial of attended PAP titration is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Polysomnography; age 6 years or older, sleep staging with 4 or more additional 
parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, 
attended by a technologist (95811) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Polysomnography.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided 
on April 28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the services were 
provided by a non-participating provider and are not eligible for coverage. 
 
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 established patient assisted living visit (99336) 
provided on April 28, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
3, 2020 to June 10, 2020. 
 
You asked the Plan to pay for home health 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 are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a corrected 
claim will be needed to be billed with a valid Health Insurance Prospective Payment System (HIPPS) code, a 
valid 18-digit alphanumeric treatment authorization code, a correct type of bill, and a valid 5-digit computer 
based statistical area (CBSA) code. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from June 3, 2020 to June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto tablets. 
 
You asked the Plan to pre-approve Entresto tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Entresto tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 pre-approve Entresto tablets.  
 
Benefits for Entresto tablets 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 pre-approve the Epoetin Beta injections (J0887) to be provided by an 
out of network provider. 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says there are network providers that can provide these services. 
 
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 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 
the Epoetin Beta injections (J0887) to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level referral to a urologist for an MRI of the 
pelvis 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are contracted non-tertiary urologists available. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 referral. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found tertiary level referral to 
a urologist for an MRI of the pelvis is not medically necessary. The evaluation and management of elevated 
PSA are not considered.tertiary care. In-network imaging facility and urologists are available. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral to a urologist for an MRI of the pelvis
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the spinal procedure. You say that the interspinous space placement is 
medically necessary. The Plan denied your request. The Plan says this device is considered investigational and 
is not covered. 
 
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 spinal procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex Superion Interspinous device is experimental. More research is needed 
to show safety and efficacy. 
 
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 spinal procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jatenzo capsules. 
 
You asked the Plan to pre-approve Jatenzo capsules. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Jatenzo capsules are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 pre-approve Jatenzo capsules.  
 
Benefits for Jatenzo capsules 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided August 21, 2020 
 
You asked the Plan to pay for the acupuncture services. You say that upon verification of the policy you were 
informed there is a 0 visit maximum for ACU services along with 100% coverage. Reference paid claim of 
member's claim history. Paid and same CPT's. The Plan denied your request. The Plan says the services were 
not performed by a physician or under the supervision of a physician (or equivalent.) Per the EOC the person 
providing acupuncture must be a physician licensed to perform the service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Per the EOC the person providing acupuncture must 
be a physician licensed to perform the service. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services with CPT code 11043 provided on 
June 18, 2020. 
 
You asked the Plan to pay for CPT code 11043. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 11043 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of CPT code 11043 have not been met.  
Therefore, we decided that the Plan does not have to pay for the debridement services with CPT code 11043 
provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid testing (84443) provided February 6, 2020. 
 
You asked the Plan to pay for the thyroid testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim did not include a valid diagnosis and this test was for screening 
purposes. 
 
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 test at issue in this appeal, thyroid testing, 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 
thyroid testing (84443) provided February 6, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve CPT Code 22845, 22853, 22558 and 22585. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not necessary. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee presents with progressive low back pain and anterior thigh pain. There is imaging 
evidence of significant degenerative changes at L4/5 and L5/S1 with dynamic instability at L5/S1. The enrollee 
has exhausted conservative treatment. Under consideration is a request for L4/5, L5/S1 anterior lumbar 
interbody fusion with L4-S1 posterior instrumented fusion. Evidence based medical peer reviewed literature 
supports the use of lumbar fusion for patients with degenerative disc disease with radiating pain (associated 
with severe degenerative changes and in the setting of instability.) Therefore, in this reviewer?s opinion, this 
request for L4/5, L5/S1 anterior lumbar interbody fusion with L4-S1 posterior instrumented fusion would be 
considered medically reasonable and necessary. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. 
Therefore, we decided that the Plan has to pre-approve CPT Code 22845, 22853, 22558 and 22585.  
 
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.