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

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration (CPT 
code D9610) and removal of impacted tooth - completely bony (CPT code D7240). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
parenteral drug, single administration (CPT code D9610) and removal of impacted tooth - completely bony 
(CPT code D7240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (78801). 
 
You asked the Plan to pre-approve radiopharmaceutical localization of tumor. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary in this case because there is insufficient information to show that the enrollee's symptoms are due to 
amyloid transthyretin and not immunoglobulin light chain amyloidosis. 
 
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 radiopharmaceutical localization of 
tumor. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the issue in this case is the medical appropriateness and 
necessity of single-photon emission computerized tomography (SPECT) imaging in the clinical evaluation of 
this enrollee. The records do not show evidence of ATTR (amyloid transthyretin). There is no clinical evidence 
provided to support the performance of SPECT imaging in this enrollee according to current guidelines. As a 
result, at this time SPECT imaging would not be considered medically reasonable and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiopharmaceutical localization of tumor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, inflammatory 
process or distribution of radiopharmaceutical agent(s) (78801).
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where he/she is currently receiving care. There are no services available at the LTACH that you 
require that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are able 
to be furnished safely and effectively only on an inpatient basis. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on August 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel.  
 
We looked at the file and Medicare rules. In this case, the therapy services were not provided under the direct 
supervision of a physician or NPP. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76705) provided on January 21, 2022. 
 You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied 
your request. The Plan says this was not billed with a necessary modifier. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate 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 pay for an ultrasound (76705) provided on January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 is being treated for 
spondylosis without myelopathy or radiculopathy. He presented with persistent pain in the lumbar spine. There 
is an associated weakness. The exam reveals a very flat lumbar spine. No scoliosis is noted. The documentation 
is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. The Intracept proedure is 
not reasonable or medically necessary at this time. 
 
 
 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 an Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from June 24, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that while you are improving, you are not at the point of 
being safe to go home. The Plan denied your request. The Plan says you no longer require skilled services and 
the continuation of SNF 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 physician reviewer 
found there is no documentation that further daily skilled services are required. After almost four weeks of 
daily inpatient skilled therapy, provided records document little functional improvement. Transition to part 
time therapy now appears to be indicated. There is no documentation that the patient requires the services on an 
inpatient basis, only in a SNF setting. Records do not document services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 continuation of SNF care from June 24, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (CPT code 99205) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the documentation received indicates medically necessary services are 
available in the 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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the record 
indicates that you have malignant mesothelioma of the pleura. The record indicates that there are in-network 
providers available to provide the requested service. The record provided does not indicate that urgently needed 
services are required because of an unforeseen illness or condition and it is not reasonable to get the services from the plan.  The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office visit (CPT code 99205) to be provided by an out-of-
network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computer-assisted surgical navigational procedure 
(20985) provided on November 10, 2021. 
 
You asked the Plan to pay for the computer-assisted surgical navigational procedure. You say that you would 
like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says payment 
cannot be made for these services when rendered by a surgical assistant. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the computer-assisted surgical 
navigational procedure (20985) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999), 
comprehensive oral evaluation - new or established patient (D0150), intraoral - complete series of radiographic 
images (D0210), reline mandibular partial denture (direct) (D5741) provided June 22, 2021, and the 
unspecified preventative procedure, by report provided July 9, 2021. 
 
You asked the Plan to pay for the unspecified preventative procedure, comprehensive oral exam, complete 
series of x-rays and reline lower partial denture. You say that you were told the services would be covered. The 
Plan denied your request. The Plan says the unspecified preventative procedure and reline lower partial denture 
are not covered under your benefits. You have exceeded the frequency limits for the comprehensive oral exam 
and complete series of x-rays. 
 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 the 
comprehensive oral exam once every three years and complete series of x-rays once every five years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
x-rays were previously covered on February 1, 2017, and a comprehensive oral exam was previously covered 
on April 11, 2019. Based on this information, we decided that the Plan's frequency limits for coverage of the 
comprehensive oral exam and complete series of x-rays have been exceeded. Though the Plan offers dental 
benefits in excess of Medicare coverage, the unspecified preventative procedures and reline lower partial 
denture are not among those covered services.  Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure, by report (D1999), comprehensive oral evaluation - new or established 
patient (D0150), intraoral - complete series of radiographic images (D0210), reline mandibular partial denture 
(direct) (D5741) provided June 22, 2021, and the unspecified preventative procedure, by report provided July 
9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you have multiple appointments coming 
up soon that you have no way of getting to. The Plan denied your request. The Plan says the denial of 
authorization for additional routine transportation trips is correct, because routine transportation beyond 30 
one-way trips per year is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298), provided on November 2, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was obtained out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only purchased through the Plan's hearing vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aids (V5298), provided on November 2, 2021.
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 current evidence-based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition as discussed above. 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 pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model without calibrated 
gradient pressure (CPT code E0651) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out of-network DME. You say that you need to improve circulation in 
your legs, you need as these boots they are the only ones that will fit you and have the air compression for your 
feet for the size you need. The Plan denied your request. The Plan says your records received do not indicate 
that you have an emergent or urgent medical condition or are in need of specialized service(s) that are not 
available in the network. The Plan states you have a Health Maintenance Organization (HMO) plan. The Plan 
states there are in-network provider(s) within a reasonable distance from your location that can provide this 
service or item and you can find a list of in-network providers in your Provider Directory. 
 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 
segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and pneumatic 
compressor, segmental home model without calibrated gradient pressure (CPT code E0651) to be provided by 
an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the requested facility does not offer services that cannot be 
met at the current facility. 
 
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. You appear 
to be more stable and improving and should only require short-term additional acute care services that can 
safely be administered at the current facility until appropriate for a lower level of care. You do not require 
services at the LTACH that are not already available at the current facility. Our physician reviewer found that 
your condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you 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 IRF admission and services.