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

 
We decided that the Plan does not have to pay for the dental services (D0120, D1110, D0274) provided on 
January 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that your contract had not 
started yet. The Plan denied your request. The Plan says your contract with the Plan as an in-network provider 
started on January 13, 2021, once the credentialing process had completed. Prior to this date, you were an out-
of-network provider, and out-of-network dental care is not covered by this plan. 
 
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 requires 
supplemental dental care to be received from a provider in the Plan's dental vendor network. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network supplemental dental 
services are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
dental services (D0120, D1110, D0274) provided on January 6, 2021.  
Your complaint about the clarity of your network contract start date is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950), retainer crowns (D6740 x 2), 
and pontic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you need a bridge since you had a tooth 
extracted. You say that this is not for cosmetic purposes. You say that since these services are medically 
necessary, you feel that your $1,000 dental benefit should be authorized to use for these services. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
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 core build up, retainer crowns, and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve core build up (D2950), retainer crowns (D6740 x 2), and pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation services (D9222, D9223 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you need to be sedated for the procedures. 
You say that your teeth are infected. You also say that local anesthesia will not numb you enough to remove 
your teeth. The Plan denied your request. The Plan says the services were denied correctly. 
 
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 deep 
sedation services (D9222, D9223 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve a complete denture. You say that you had a previous denture made but it 
was oversized, and you returned it. The Plan denied your request. The Plan says you had a previous complete 
lower denture provided on September 2, 2021. This service is only covered once every 60 months. 
 
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 can cover one 
complete lower denture every 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. The documentation shows that you received a previous lower denture in 
September of 2021, and there is no documentation to support that this denture was returned to the provider or 
that the Plans payment to the provider was returned to the Plan. Therefore, we decided that the Plan does not 
have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 bone grafts (D7950) and sinus augmentation (D7952) for the upper right and upper left quadrants.

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the requested services are not covered.

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 bone grafts and sinus augmentation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 16 bone grafts (D7950) and sinus augmentation (D7952) for the upper right and upper left quadrants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (CPT code 77061) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. CPT code 77061 has status code "I" which is not valid for Medicare purposes. Medicare uses another 
code for reporting of and payment for these services. 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 pay for 
diagnostic digital breast tomosynthesis (CPT code 77061) provided on December 1, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 in the Medicare rules section. 
 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  The documentation does not support that the enrollee requires at least 3 hours a day / 5 
days a week, or 15 hours over 7 consecutive days, of therapy services. There is not a reasonable expectation 
that the enrollee 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: 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. The Plan denied your request. The Plan says IRF care is not 
considered medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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. Our reviewer found that the enrollee is functioning at a level commiserate with his injury 
and weight-bearing status. Our physician reviewer also found that the enrollees care needs can be met at a 
lower level of care. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on February 19, 2021
and billed under code G0483.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and provided documentation to show how many drug classes had been tested. The
testing results show only 14 classes were tested, meaning code G0483 was inappropriately billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the Plan has
provided lab results to show less than 22 classes were tested, meaning this claim was not coded appropriately.
Medicare uses another code for testing resulting in less than 22 classes of drugs. Therefore, we decided that the
Plan does not have to pay for drug testing provided to the enrollee on February 19, 2021, and billed under code
G0483.
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 enrollee needs the rehabilitation due to weakness 
and being unstable due to the stroke. The enrollee was independent before the stroke and needs to get her 
independence back. The Plan denied your request. The Plan says authorization denied because the IRF care is 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 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 medical problems are stable, and there are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the NeuraGen Nerve Guide. 
 
You asked the Plan to pre-approve the NeuraGen Nerve Guide. You say that the requested procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says that the requested procedure 
is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the NeuraGen Nerve Guide. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee is a 75-year-old female who was being treated for lesion of 
ulnar nerve, right upper limb; right elbow contracture. She presented with continued right elbow stiffness, 
soreness, and weakness along with continued complaints of right-hand numbness, tingling, and weakness 
despite both surgical and nonsurgical treatment in the past. Exam reveals elbow range of motion is limited at 
30-130 on the right, supination is 80 and pronation is 85. There is tenderness over the medial elbow and 
tenderness over the ulnar nerve. There is tenderness and triggering of her left middle finger. There is decreased 
sensation in the ulnar nerve distribution with a positive Tinels at the right cubital tunnel. Wartenbergs test 
was positive. Provided documentation demonstrates subjective and objective deficits that are corroborated by 
imaging studies. She has failed 2 previous ulnar nerve neurolysis procedures. The requested conduit has been 
approved by the Food and Drug Administration and supported in recent peer-reviewed literature. Therefore, the 
requested NeuraGen Nerve Guide, in this case, is medically reasonable and necessary. 
d 
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 NeuraGen Nerve Guide have been met. Therefore, we decided that the Plan 
has to pre-approve the NeuraGen Nerve Guide.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Isto InQu allograft and bone marrow aspirate. 
 
You asked the Plan to pre-approve Isto InQu allograft and bone marrow aspirate. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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 Isto InQu allograft and 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 InQu allograft and bone marrow aspirate remain 
experimental. More research is 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 Isto InQu allograft and bone marrow aspirate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Isto InQu allograft and bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcatheter Aortic Valve Replacement (TAVR). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
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 requested services are not considered medically reasonable and necessary in this case. A recent visit with 
the consulting cardiovascular surgeon reports that the patient is very active...bikes several miles a day...is 
difficult to get him to describe any symptoms. The most recent echocardiogram showed aortic stenosis, with 
valve area 0.9 sq cm and normal left ventricular function. Guidelines would not support aortic valve 
replacement based on the submitted medical records. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Transcatheter Aortic Valve Replacement (TAVR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a L300 Go System. 
 
You asked the Plan to pre-approve a L300 Go System. You say that the requested L300 Go System is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
L300 Go System. 
 
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 L300 Go System. Our reviewer says 
that the enrollee does not meet criteria for the L300 Go System. Our physician reviewer found according to the 
applicable NCD; the requested item is only covered for use in patients with a history of a spinal cord injury 
(SCI) when additional requirements for coverage are met. In this case the member does not have a history of 
SCI. Nor are they "at least 6-month post recovery spinal cord injury and restorative surgery".  In this 
setting/context the base requirements for coverage of this service would not have been met. This would not 
satisfy the Medicare requirements for coverage of this service. 
 
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 L300 Go System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a L300 Go System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty scooter (K0801). 
 
You asked the Plan to pre-approve the heavy-duty scooter. You say that you would like reconsideration 
because you cannot walk and using the manual wheelchair is too dangerous. The Plan denied your request. The 
Plan says documentation submitted on appeal does not include a face-to face evaluation by your provider for a 
POV, an order 
for a POV, or a home evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that all of the criteria listed in the Medicare rules 
section must be met in order for a power mobility device to be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the heavy duty scooter have not been met. Specifically, the documentation submitted does not 
include evidence of a face-to-face evaluation for the scooter, a physician order or a home evaluation. Therefore, 
we decided that the Plan does not have to pre-approve a heavy-duty scooter (K0801).
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 enrollee currently meets the full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for an admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that 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.