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

We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
You asked the Plan to pre-approve upper and lower partial dentures. You say that you would like this service covered. The Plan denied your request. The Plan says dentures are not covered under your 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 maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the
member has failed years of conservative approaches to treatment, and this is the best option at the time. You
say that this plan is out of compliance with Medicare guidelines by not providing coverage. The Plan denied
your request. The Plan says the procedure is 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 the insertion of stabilization device
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our reviewer says that the spinous process stabilization devices remain
experimental.
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 insertion of stabilization device (22869 and 22870) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869
and 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metaxalone.
You asked the Plan to pre-approve Metaxalone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Metaxalone.
Benefits for Metaxalone 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).

You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that the science supporting this treatment is far great than many other procedures that coverage is provided. You say that the member has failed conservative treatment and the denial that this is considered investigational is not appropriate. The Plan denied your request. The Plan says unproven and not medically necessary procedures are 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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer says that the interosseous nerve ablation remains experimental for back pain treatment. 

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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.

You asked the Plan to pre-approve Entresto. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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.

Benefits for Entresto 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Genium microprocessor knee (L5828, L5845,
L5848, L5850 and L5858).

You asked the Plan to pre-approve the Genium microprocessor knee. You say that you would like
reconsideration because the requested Genium microprocessing knee is medically necessary. The Plan denied
your request. The Plan says per DME PDAC, this is not approved for use of the requested coding.

The Plan must follow Medicare rules. Medicare rules say that use of the appropriate HCPCS code assures that
accurate processing can be accomplished resulting in a proper claim determination and reimbursement.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Genium microprocessor knee have not been met. Per the DME PDAC and the manufacturer's
website, this coding is not appropriate for Medicare coverage for the requested Genium microprocessor knee.
Therefore, we decided that the Plan does not have to pre-approve the Genium microprocessor knee (L5828,
L5845, L5848, L5850 and L5858).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the microsurgery add-on (69990).
You asked the Plan to pre-approve the microsurgery add-on (69990). The Plan denied your request. The Plan says CPT codes 22612, 20930 and 22840 were approved. The Plan also says code 69990 is upheld due to the program bundle for related surgical procedures.
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, we have confirmed that code 69990 is a column II code to column I code 22612. This claim cannot be billed with a modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pre-approve the microsurgery add-on (69990).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Benefits for Synvisc One 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 pre-approve an auricular stimulator.

You asked the Plan to pre-approve the requested services. You say that the device would help the enrollee with chronic pain and reduce the use of narcotics. The Plan denied your request. The Plan says the requested service is 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 looked at the file, and Medicare rules. The requested service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image guided lumbar decompression procedure (0275T).

You asked the Plan to pre-approve the percutaneous image guided lumbar decompression procedure. You say that this service is medically necessary. The Plan denied your request. The Plan says this procedure is not covered unless part of an approved clinical trial.

The Plan must follow Medicare rules. Medicare rules say that percutaneous image guided lumbar decompression is considered experimental/investigational and not covered under Medicare if performed outside of clinical trials. 

We looked at the file and Medicare rules. This procedure is not being performed as part of a clinical trial. Based on this information, we decided that Medicare rules for coverage of the percutaneous image guided lumbar decompression procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image guided lumbar decompression procedure (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3230).
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and crowns - porcelain/ceramic (D2740).
You asked the Plan to pre-approve the core buildup and porcelain/ceramic crowns. You say that you dentist says these services are necessary. The Plan denied your request. The Plan says these services are not covered under your 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 when required (D2950) and crowns - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation -
new or established patient (D0150) and panoramic radiographic image (D0330) provided October 5, 2021, by
an out-of-network (OON) provider.
You asked the Plan to provide additional payment for the comprehensive oral exam and panoramic x-ray. You
say that you would like the services covered. The Plan denied your request. The Plan says the cost-sharing has
been applied correctly according to your OON 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. The Plan covers the
comprehensive oral exam and panoramic x-ray with a $10 copayment for each service. The enrollee is
responsible for balances up to the dentist's charge for services provided OON.
We looked at the file and Medicare rules. In this case the dental services were provided by an OON provider.
The Plan provided documentation showing that the enrollee was assessed a $10 copayment for each service.
Additionally, since the services were provided OON, the enrollee is responsible for the difference between
what the Plan paid and the total cost billed by the OON provider. Based on this information, we decided that
the Plan's rules for coverage of the comprehensive oral exam and panoramic x-ray have not been met.
Therefore, we decided that the Plan does not have to provide additional payment for the comprehensive oral
evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided October
5, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
You asked the Plan to pre-approve intravenous moderate (conscious) sedation/analgesia. You say that the enrollee needs this service covered. The Plan denied your request. The Plan says that the requested service is not covered under the enrollee's 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. The Plan covers intravenous moderate (conscious) sedation/analgesia. We looked at the file and Medicare rules. In this case the contract clearly says that intravenous sedation (D9239 and D9243) is covered under the enrollee's benefits. Based on this information, we decided that the Plan's rules for coverage of intravenous moderate (conscious) sedation/analgesia have been met. Therefore, we decided that the Plan has to pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-precision abutments - placement (D6191), semiprecision
attachments - placement (D6192), surgical placement of implant body: endosteal implants (D6010),
surgical access to an implant body (second stage implant surgery) (D6011), implant /abutment supported
removable denture for edentulous arch - maxillary (D6110), replacement of replaceable part of semi-precision
or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment
(D6091), and implant /abutment supported removable denture for edentulous arch - mandibular (D6111).

You asked the Plan to pre-approve semi-precision abutments, semi-precision attachments, endosteal implants,
surgical access to implants, replacement of replaceable part of semi-precision or precision attachment of
implant/abutment supported prosthesis and implant/abutment supported removable denture. You say that you
have trouble eating foods and would like the services approved. The Plan denied your request. The Plan says
these services are not covered under your 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
semi-precision abutments - placement (D6191), semi-precision attachments - placement (D6192), surgical
placement of implant body: endosteal implants (D6010), surgical access to an implant body (second stage
implant surgery) (D6011), implant /abutment supported removable denture for edentulous arch - maxillary
(D6110), replacement of replaceable part of semi-precision or precision attachment (male or female
component) of implant/abutment supported prosthesis, per attachment (D6091), and implant /abutment
supported removable denture for edentulous arch - mandibular (D6111).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 7, 2021.
You asked the Plan to pay for the laboratory 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left trans-radial prosthesis additions of microprocessor control (L6882), additional external power switch (L6611), and automatic grasp features (L6881).
You asked the Plan to pre-approve the left trans-radial prosthesis additions of microprocessor control, additional external power switch, and automatic grasp features. You say that the items are medically necessary. The Plan denied your request. The Plan says these items are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the left trans-radial prosthesis additions of microprocessor control (L6882), additional external power switch (L6611), and automatic grasp features (L6881).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that 60 full days of hospitalization plus 30 coinsurance days represent the maximum benefit period.
We looked at the file, and Medicare rules. The record shows the enrollee's inpatient benefit has been exhausted. 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 continued long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the stairway lift (E1399).
You asked the Plan to pre-approve the stairway lift. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not primarily and customarily used to serve a medical purpose and is generally useful to a person in the absence of illness or injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the stairway lift (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and complete
denture - mandibular (D5120).

You asked the Plan to pay for complete upper and lower dentures. You say that you would like the dentures
covered. The Plan denied your request. The Plan says dentures are not covered under your 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 pay for a
complete denture - maxillary (D5110) and complete denture - mandibular (D5120).