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

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (CPT Code 78452). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our physician reviewer 
found unfortunately, although the intentions for the results of the study are good, there is no obligation for the 
insurer to authorize a study that is not medically indicated. Denial 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, 
qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 
quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or 
redistribution and/or rest reinjection (CPT Code 78452).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is covered when specific 
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 pre-approve these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has grade 2 
invasive ductal carcinoma, strongly ER/PR positive at 95 percent/20 percent, HER2 1 positive. The enrollee's 
family history is notable for stomach cancer in her brother, and bladder cancer in her brother. There is no 
documented family history of breast or ovarian cancer. The enrollee does not have triple negative breast cancer, 
ovarian cancer, or pancreatic cancer, there is no known deleterious BRCA1 or BRCA2 gene mutation, and 
there is not a documented family history of qualifying cancer. The criteria for coverage are not met and the 
testing is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins, tooth 14 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing because your dentist said 
that they were not going to use pins or posts in your procedure. The Plan denied your request. The Plan says 
this service is not covered under the plan benefits. 
 
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 core 
buildup, including any pins, tooth 14 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction (D7210) intravenous moderate 
(conscious) oral surgery anesthesia (D9239, D2943) therapeutic parenteral drugs (D9612L to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial for extractions 
and sedation. The procedure would cost $3,084 and you cannot afford off the work. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 
surgical extraction (D7210) intravenous moderate (conscious) oral surgery anesthesia (D9239, D2943) 
therapeutic parenteral drugs (D9612L to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
provider is out-of-network with the Plan and the enrollee can be treated within the Plan network. 
 
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 medical services 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 admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says in order for this to be approved, your condition must meet the criteria. 
 
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 the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9940). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need this guard to prevent your teeth 
from grinding. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 an 
occlusal guard (D9940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), the 
additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on August 20, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you received a bill. You say that only $54 of the 
$170 total was paid. You say that you were never advised of changes made to your policy stating that cleanings 
and x-rays are only covered once per year. You also say that you have always visited the dentist every 6 
months. The Plan denied your request. The Plan says 1 periodic oral exam is covered per calendar year. The 
Plan says that 1 prophylaxis is covered per calendar year. The Plan says that 1 periapical x-ray is covered per 
calendar year. The Plan also says that the frequency limits for these services have been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limits of 1 oral exam, 
cleaning and periapical x-ray per calendar year have been exceeded. The record shows that the Plan paid for the 
oral exam and cleaning that you received on February 4, 2020. The record shows that the Plan paid for the 
initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan 
does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), the additional periapical x-ray 
(D0230), and the unspecified preventive service (D1999) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam and unspecified preventive procedure provided 
on August 5, 2020. 
 
You asked the Plan to pay for the services provided. You say that you were given the names of in-network 
providers. The Plan denied your request.  
 
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 file shows that an oral exam was provided on August 5, 2020. You last received an oral exam on April 29, 
2019. We looked at the file and the rules. Oral exams are only covered once every three years. Based on this 
information, we decided that the Plan?s rules for coverage have not been met.  
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the provided unspecified preventive 
service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the oral exam and unspecified preventive procedure provided on August 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto 15 mg tablet. 
 
You asked the Plan to pre-approve Xarelto. You say that this service is medically necessary. The Plan denied 
your request. The Plan says drug coverage is limited only to those drugs covered under your medical 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 Xarelto 15 mg tablet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tikosyn 250mcg capsule medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
enrollee's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Tikosyn 250mcg 
capsule medication.  
 
Benefits for this medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services rendered on June 3, 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 procedure codes 74177, 71260, 72125, 70486, and 70450 are 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 74177 is computed tomography, abdomen and pelvis; 
with contrast material(s). The definition of code 71260 is computed tomography, thorax; with contrast 
material(s). The definition of code 72125 is computed tomography, cervical spine; without contrast material. 
The definition of code 70486 is computed tomography, maxillofacial area; without contrast material. The 
definition of code 70450 is computed tomography, head or brain; without contrast material. 
 
We find that CPT codes 74177, 71260, 72125, 70486, and 70450 not supported in the medical record. 
Specifically, there is no documentation of a CT scan of the abdomen/pelvis to support code 74177. There is no 
documentation of a CT scan of the thorax to support code 71260. There is no documentation of a CT scan of 
the cervical spine to support code 72125. There is no documentation of a CT of the maxillofacial area to 
support code 70486. There is no documentation of a CT scan of the head/brain to support code 70450. 
 
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 radiology services rendered on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant 
supported porcelain fused to metal crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that 
these services are needed in order to complete the implant procedure. The Plan denied your request. The Plan 
says these services are not covered under the enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
custom fabricated abutment (D6057) and implant supported porcelain fused to metal crown (D6066).
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. 
 
You asked the Plan to pre-approve IRF care. You say that the request is medically necessary. The Plan denied 
your request. The Plan says the rules for IRF care have not been met. 
 
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 the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The Superion spacer is considered experimental in nature, as more research is needed to show safety and 
efficacy. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on 
September 8, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you could have gotten 
the supplies somewhere else for cheaper. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies on September 8, 2020. The total allowed amount is $539.80 and 20% 
of that is $107.96.  
 
You have been asked to pay the total coinsurance amount of $107.96 for DME and related supplies. DME and 
related supplies fall within the DME and related supplies 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 DME and related supplies provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks of the L4-5 spine for the enrollee. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not had physical therapy. 
 
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 blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is another probable source of pain - the disc contacting the L5 nerve root. The enrollee has not had 
recent physical therapy. 
 
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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve medial branch blocks of the L4-5 spine for the enrollee.