Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve home health services. You say that home health services are necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered. The file does not show that the enrollee is homebound. Therefore, we decided that the 
Plan does not have to pre-approve home health services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump. 
 
You asked the Plan to pre-approve a NPWT pump. You say that this item was ordered by your doctor after a 5-
day hospital stay for an open wound on the foot. It was denied because the Plan said you were diabetic, but you 
are not diabetic. The Plan denied your request. The Plan says you do not meet criteria for this item. The records 
do not show that you had optimized wound care and diabetic management. 
 
The Plan follows Medicare rules. Medicare rules say that in order for a NPWT pump to be covered for your 
type of ulcer, you would have had to have been on a comprehensive diabetic management program, and 
reduction in pressure on the ulcer has been accomplished with appropriate modalities  
 
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 NPWT pump. Our reviewer says that 
a NPWT pump is not medically necessary. Our physician reviewer found you have a diabetic ulcer on the right 
foot. The record sent by the provider indicates that you underwent debridement of the ulcer on October 24, 
2022. The reviewed records do not document that there has been on a comprehensive diabetic management 
program. Therefore, you do not meet criteria for the negative pressure wound therapy pump. 
 
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 NPWT pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a negative pressure wound therapy (NPWT) pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is a high risk for a poor 
outcome including death if they are given care at a lower level. You say that the enrollee is stable and ready to 
start their rehabilitation process with an LTACH. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's medical needs can be met in their current 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. Our 
physician reviewer found the enrollee is more stable and should only require short-term additional acute care 
services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 6, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this service is medically necessary. The 
Plan denied your request. The Plan says bone marrow aspirate to be used with anterior cervical discectomy and 
fusion is not medically necessary. Bone marrow aspirate is considered experimental/investigational and is 
therefore non-covered. The Plan has approved the surgery, the denial is for the bone marrow aspirate only. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and 
efficacy when used as bone graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided on May 6 through June 
10, 2022. 
 
You asked the Plan to pay for the behavioral health services. You say that the provider is active with Medicare 
and should be reimbursed. The Plan denied your request. The Plan says the provider type that billed is not 
eligible in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules say that  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The provider shows to be a Licensed Independent Clinical Social Worker (LICSW). This provider 
type is not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to pay for 
behavioral health services provided on May 6 through June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve a sacral nerve stimulator. You say that the patient is having bathroom issues 
and has failed with medication. The Plan denied your request. The Plan says a sacral nerve stimulator is not 
medically necessary. The records do not show that the patient has benign prostatic hypertrophy with outflow 
obstruction. 
 
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 sacral nerve stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found sacral neuromodulation is not medically necessary for enrollees that have benight 
prostatic hypertrophy (BPH) with bladder outlet obstruction as this enrollee has. Sacral neuromodulation is 
indicated for non-obstructive urinary retention and overactive bladder/urge incontinence.   
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Facet Joint Interventions (64493 and 64494). 
 
You asked the Plan to pre-approve Facet Joint Interventions. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria listed in the 
Medicare Rules sections 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 Facet Joint Interventions. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the records do not show any 
imaging of the spine. The patient has degenerative back pain, but there is no record of previous injection 
therapy or improvement with such either is included. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Facet Joint Interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Facet Joint Interventions (64493 and 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion Device. 
 
You asked the Plan to pre-approve the surgery to place a Vertiflex Superion Device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 surgery to place a Vertiflex 
Superion Device. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this service is experimental, and more research is needed 
on its 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 surgery to place a Vertiflex Superion Device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion Device.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2740) for tooth #31 provided by a participating provider on 
May 19, 2022. 
 
You asked the Plan to pay for a crown. You say that these services are medically necessary. The Plan denied 
your request. The Plan says that a crown is 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 Plans coverage rules apply in this case. The Plan covers a crown 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 pay for a crown. Our physician reviewer found the 
medical criteria for a crown have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pay for a 
crown (D2740) for tooth #31 provided by a participating provider on May 19, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the patient needs continued rehab following back 
surgery. He is unable to standing or walk and requires full-time care, and additional rehab is needed. The Plan 
denied your request. The Plan says the patient no longer requires skilled services on a daily basis, so continued 
SNF care as of November 17, 2022, is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that from a nursing perspective, the patient received oral medications and has stable 
vital signs.  He has been treated for pain. Regarding rehabilitation services, the patient has received physical 
and occupational therapy. The patient is at a moderate assist level with bed mobility and dependent with 
transfers.  He requires varying assistance with activities of daily living. The patient has no identifiable skilled 
nursing or skilled therapy needs at this time. The patient does not meet severity of illness or intensity of service 
criteria on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it is not known whether or not the enrollee failed to improve after six weeks of 
conservative therapy including activity modification, exercise, medications, or physical therapy. 
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the enrollee has a 
complex history of fusion T3-ilium. The enrollee presents with both lower and upper extremity radicular 
symptoms. The enrollee has pain in her shoulders and a prior MRI of the cervical spine showed progressive 
stenosis at C4-5. The nature of her extensive fusion surgery and the consideration of facet injections for her 
upper extremity pain are facts that make the requested MRI of the cervical and thoracic spine reasonable 
requests even without physical therapy given the extensive surgery in the past. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the cervical spine.  
 
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 pay for the osseous surgery (including elevation of a full thickness 
flap and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), occlusal 
adjustment - limited  (D9951), bone replacement graft for ridge preservation - per site (D7953), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210), and guided tissue regeneration - resorbable barrier, per site (D4266) provided on 
April 21, 2022, and July 5, 2022. 
 You asked the Plan to pay for the dental services. You say that you thought all these procedures were covered 
under your dental or medical policy with the Plan. You called and added the extra dental and you were 
surprised that these were not covered at all. The Plan denied your request. The Plan says these services are not 
covered under the 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 pay for the 
osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261), occlusal adjustment - limited  (D9951), bone replacement graft for 
ridge preservation - per site (D7953), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and guided tissue regeneration - 
resorbable barrier, per site (D4266) provided on April 21, 2022, and July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental consultation and the surgical extraction to be 
provided by an Oral Surgeon. 
 
You asked the Plan to pre-approve the consultation and the surgical extraction. You say that you need to have 
the tooth pulled because it is infected. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 only 
covered when performed by a participating general dentist. Therefore, we decided that the Plan does not have 
to pre-approve the dental consultation and the surgical extraction to be provided by an Oral Surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allograft services coded 20931, 20936, and 20930 
provided on May 6, 2022. 
 
You asked the Plan to pay for the allograft services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20931, 20936, and 20930 is not supported in the medical record. Specifically, multiple 
assistants are not covered for code 20931. Codes 20936 and 20930 are not covered as separately billed 
services/tests have been bundled as they are considered components of the same procedure. Based on this 
information, we decided that Medicare rules for coverage of the allograft services have not been met. Therefore, we decided that the Plan does not have to pay for the allograft services coded 20931, 20936, and 
20930 provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic radiographic image (D0330), intravenous (IV) moderate 
(conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous (IV) moderate (conscious) 
sedation/analgesia  each subsequent 15-minute increment (D9243) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover these services. 
 The Plan denied your request. The Plan says that your benefit for the panoramic x-ray has already been 
exhausted and the IV sedation is not covered under your benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the panoramic x-ray was previously 
exhausted. Additionally, the Plan contract does not clearly say what specific service are covered or not covered. 
It is not clear that IV sedation is not covered under the enrollees benefits. Therefore, we decided that the Plan 
has to pay for the panoramic radiographic image (D0330), intravenous (IV) moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), and intravenous (IV) moderate (conscious) sedation/analgesia  
each subsequent 15-minute increment (D9243) provided on August 2, 2022.  
 
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.