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

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of all 
quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
periodontal scalings and root planings are not medically necessary. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has noted increased 
pocketing as seen on the provided periodontal charting, however the provided radiographs do not reveal any 
loss of bone in any quadrant which would be necessary to have a diagnosis of periodontitis. Our reviewer found 
that as there is no discernible loss of bone in any quadrant, there would be no root surfaces exposed to scale.  
Given the criteria of needing four or more affected teeth with either root surface caries or notable loss of bone 
support, there would be no necessity found for the requested procedures. Our physician reviewer also found 
that the lack of any noted bone loss would not allow for a proper diagnosis of periodontitis, and therefore no 
necessity for a periodontal treatment. 
 
 
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 all quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for services provided. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation did not include an itemized invoice, or a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The documentation shows that payment for electrical stimulator supplies, a shoulder elbow wrist hand orthosis, 
and an ankle-foot orthosis was requested. The record does not contain a valid proof of delivery for electrical 
stimulator supplies (A4595). The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. A review of the file does not show that the telehealth service was provided in 
an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare 
program and cannot substitute for an in-person encounter. Consequently, the items ordered following the non-
covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment billed for services provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport 
provided on June 29, 2020. 
 
You asked the Plan to waive this copayment. You say that they did not treat you in the ambulance and you do 
not feel you should have to pay the copayment. The Plan denied your request. The Plan says this copayment is 
a contractual obligation. 
 
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 $225 
copayment for ambulance transport. 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 $225 copayment charged for ambulance 
transport provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spinal fusion. 
 
You asked the Plan to pre-approve the lumbar spinal fusion. You say that you are in constant pain. You say that 
you cannot stand alone. The Plan denied your request. The Plan says the documentation does not show that the 
enrollee has sagittal imbalance. The Plan says that the criteria for coverage of back surgery have 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 the lumbar spinal fusion. Our reviewer 
says that a lumbar spinal fusion is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear sagittal imbalance. Our physician reviewer found that there is no 
clear instability. A multilevel fusion is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar spinal fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection you received on 
June 3, 2020. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you cannot afford this 
monthly cost to save your sight. The Plan denied your request. The Plan says you were charged this amount 
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 20% 
coinsurance for Medicare Part B drugs.  
 
Records show that the allowed amount for this injection is $2158.42. You have been asked to pay 20% 
coinsurance ($2158.42 x 20% = $431.68) for the aflibercept injection. The aflibercept injection falls within the 
Medicare Part B drugs 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 coinsurance for the 
aflibercept injection you received on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for an IRF admission. 
 
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. Our 
physician reviewer found that based on review of the medical records, the enrollee does not meet the CMS 
coverage criteria for an IRF admission based on lack of medical complexity and nursing needs. The enrollee 
with debility is generally medically stable. There is no evidence of medical issues that require monitoring by an 
inpatient rehab physician three times a week. While he may benefit from PT and OT, the documentation does 
not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary 
approach to rehab care. This enrollee does not meet the CMS coverage criteria for an IRF admission. The 
enrollee's rehab needs can be met in an alternate, less intense setting. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ClariFix device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is an 
experimental/investigational procedure. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the literature supporting use of the ClariFix device is limited. There is one study that mentions a 
reduction in symptoms of rhinorrhea and congestion. However, it was sponsored by Arrinex, which is the 
company that created the device. The authors of the study are consultants for Arrinex. There was also no 
control group in the study. A second study was published in 2020, that is also industry sponsored and also lacks 
a control arm. Therefore, there is not sufficient evidence supporting use of the device. 
 
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 a ClariFix device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of Oasis Wound Matrix. 
 
You asked the Plan to pre-approve Oasis Wound Matrix. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for these services is correct, because studies have 
not proven that the use of this product is helpful for treatment of the enrollee's surgical wound. 
 
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 Oasis Wound Matrix. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this product is medically necessary for partial and full thickness neuropathic diabetic 
foot ulcers and difficult to heal chronic venous partial and full thickness ulcers of the lower extremity that have 
failed standard wound therapy. The enrollee does not have these conditions and therefore the Oasis Wound 
Matrix is not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oasis Wound Matrix have not been met. Therefore, we decided that the Plan 
does not have to pre-approve application of Oasis Wound Matrix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
December 28, 2019. 
 
You asked the Plan to pay for the services provided. You say that the visits are important to evaluate cardiac 
conditions of the enrollee. The Plan denied your request. The Plan says the service was already paid for on the 
date of service for another provider. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient. We find that CPT code 99222 is not supported in the medical record.  
Specifically, there are insufficient medical records provided to show evaluation services were provided for a 
separate and distinct condition. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services provided on December 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Medicare Part B drugs provided. 
 
You asked the Plan to waive the cost share for the provided services. You say that the service was totally 
covered on your previous insurance plan. The Plan denied your request. The Plan says the cost share is a 
contractual obligation that cannot be waived. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the provided services. The services fall within the Medicare 
Part B prescription drugs 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 cost share for the Medicare 
Part B drugs provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the patient does not appear to be stable for discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving but is not yet stable due to recent bradycardia episodes. Remaining acute care services 
is likely to not be more than 24 additional days and can be completed at the current setting. The patient does 
not require services at the LTACH that are not already available at the current hospital. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be stable but is likely to not require more than 24 additional days of acute care services. The patient 
does not require services at the LTACH that are not already available at the current hospital. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the lab services provided on June 4, 2020. 
 
You asked the Plan to waive the copay for the lab services. You say that the sample was not delivered in time 
to complete all the requested tests. The Plan denied your request. The Plan says you are financially liable for 
any cost share applied. 
 
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 $12 
copay for Medicare-covered lab tests.  
 
Although not all the tests requested were performed, you have been asked to pay a $12 copay for the lab 
services that were provided. The services fall within the outpatient diagnostic tests 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 copay for the lab services provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve lumbar ESI. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because you had an epidural in the past and 
it did not work. 
 
The Plan follows Medicare rules. Medicare rules state that repeat lumbar ESIs are covered if the prior injection 
provided at least 6 weeks of pain relief. 
 
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 lumbar ESI. Our reviewer says that you 
do not meet the Medicare criteria for the requested epidural. Our physician reviewer found the documentation 
does not support that you obtained 6 weeks of pain relief (at least 50% reduction in pain) from prior injections 
at the requested levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate level of 
care for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute 
services are required. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751) and pontics (D6241). 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that your bridge broke on the right 
side and you are having a hard time eating. You say that you have already lost 5 pounds in the last couple of 
weeks. The Plan denied your request. The Plan says the services in dispute are not covered benefits under your 
contract. 
 
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 
retainer crowns (D6751) and pontics (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided 
on June 22, 2020. 
 
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that a tooth extraction done 
with only nitrous oxide for the pain should be covered. The Plan denied your request. The Plan says this 
procedure is not included in the benefits section of your Evidence of Coverage. 
 
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 pay for the 
inhalation of nitrous oxide/analgesia (D9230) provided on June 22, 2020.