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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and Infuse BMP allograft. 
 
You asked the Plan to pre-approve bone marrow aspirate and Infuse BMP allograft. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has 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 bone marrow aspirate and Infuse BMP 
allograft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient evidence in the peer-reviewed medical 
literature to support that bone marrow aspirate and Infuse BMP allograft are medically reasonable and 
necessary 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 bone marrow aspirate and Infuse BMP allograft have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bone marrow aspirate and Infuse BMP allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient documentation in the peer-reviewed medical literature to support 
that the Intracept procedure is medically reasonable and necessary for the enrollee in this case. One double-
blind randomized study has shown that improvement with the Intracept procedure was not clinically significant 
when compared with a sham procedure. Additional studies suggest that the Intracept procedure may be more 
effective for low back pain than conservative treatment. Limitations of the published medical literature include 
a limited number of studies, industry funding of the studies, and a high risk of bias from lack of controls. 
Additional study is needed to validate any benefit of the procedure, and to compare it to other interventions. 
Current medical literature indicates that the Intracept procedure is investigational 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295 and 84479 billed for 
date of service November 11, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, 84295 and 84479. You say that these services 
were necessary and were billed appropriately. The Plan denied your request. The Plan says the payment for the 
codes at issue is bundled into the payment for other codes which were billed on this same claim. 
 
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 codes 
82435, 84132 and 84295 are column II codes to column I code 80051. Each of these code pairs has a modifier 
indicator of 1; however, these services have not been billed with an appropriate modifier to bypass the edit. In 
addition, code 84479 is a column II code to column I code 84439 with a modifier indicator of 0. The column II 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295 and 84479 
billed for date of service November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
May 4, 2022. 
 
You asked the Plan to pay for the fluoride varnish. The Plan denied your request. The Plan says the application 
of fluoride varnish is not a covered service under your dental benefit 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. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride varnish (D1206) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation (D0120) and a dental cleaning (D1110) 
provided by an OON provider on April 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been to the same provider before and 
there was never a problem. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an evaluation (D0120) and a dental cleaning (D1110) provided by an OON provider on April 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care to return to prior level 
of functioning. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF 
services do not meet the requirements for approval. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth (cutting procedure). 
 
You asked the Plan to pre-approve removal of residual tooth (cutting procedure). You say that a tooth was 
being removed and it broke off, therefore this is causing you to get life threatening gum infections. The Plan 
denied your request. The Plan says this service is not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve 
removal of residual tooth (cutting procedure).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for unspecified adjunctive procedures (D9999) provided on January 13, 
2021, prophylaxis (D1110) provided on April 22, 2021, and an unspecified adjunctive procedure (D9999), 
prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denials of these dental 
services. The Plan denied your request. The Plan says that your annual limit for dental services has been 
exhausted. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide documentation showing your annual dental limit had 
been exhausted. Therefore, we decided that the Plan has to pay for unspecified adjunctive procedures (D9999) 
provided on January 13, 2021, prophylaxis (D1110) provided on April 22, 2021, and an unspecified adjunctive 
procedure (D9999), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 26, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. 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 an SI joint injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not had an 
adequate trial of conservative therapy such as chiropractic or physical therapy. Coverage criteria requires a 12 
week trial of conservative therapy. Therefore, the request is deemed not medically reasonable or 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 an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periapical x-rays (D0220, D0230) and periodontal 
maintenance (D4910). 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plan's cost-sharing amount when your services are received from an out-of-network provider. The Plan also 
says that you have been charged the correct cost sharing amount. 
 
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. 
 
You have been asked to pay 50% coinsurance for the x-rays and periodontal maintenance provided on April 26, 2022. 
 
Code Allowed Amount 50% Coinsurance 
D0220 $20.40 $10.20 
D0230 $17 $8.50 
D0230 $17 $8.50 
D0230 $17 $8.50 
D0230 $17 $8.50 
D4910 $103 $51.50 
 
You have also been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for periapical x-rays (D0220, D0230) and 
periodontal maintenance (D4910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies and the delivery, set up, 
and/or dispensing service provided on April 8, 2021. 
 
You asked the Plan to pay for the electrical stimulator supplies and the delivery, set up, and/or dispensing 
services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
enrollee did not meet criteria for the items rendered. 
 The Plan must follow Medicare rules. Medicare rules say that NMES to treat muscle atrophy is limited to the 
treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee did not meet the NCD 
criteria listed above for the supplies provided. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies and the delivery, set up, and/or dispensing servics have not been 
met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies and the 
delivery, set up, and/or dispensing service provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 5, 2022. 
 You asked the Plan to pay for procedure code 99053. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84479 and 84480 provided May 26, 2022. 
 
You asked the Plan to pay for 84479 and 84480. You say that these services were reported correctly. The Plan 
denied your request. The Plan says the payment for these services is bundled into the payment for other 
services billed on this claim. 
 
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 84479 
is a column II code to column I code 84439 with a modifier indicator of 0 Additionally, we confirmed that code 
84480 is a column II code to column I code 84481 with a modifier indicator of 0. The column II codes are 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 84479 and 84480 provided May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods. You say that the Intracept 
procedure is medically necessary and is support by the enrollee's current medical status. The Plan denied your 
request. The Plan says this service is considered experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The Intracept procedure uses radiofrequency to treat low back pain that has persisted 
for 6 months, and is associated with type 1 or type 2 Modic changes to the L3 to S1 vertebral endplates on 
MRI. One double-blind randomized study has shown that improvement with the Intracept procedure was not 
clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept 
procedure may be more effective for low back pain than conservative treatment. Limitations of the published 
medical literature include a limited number of studies, industry funding of the studies, and a high risk of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to compare it to 
other interventions. Current medical literature indicates that the Intracept procedure is investigational 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81404, 81479) provided on June 24, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and 
were provided to an enrollee with affirmative personal history of cardiovascular disease in order to determine 
additional hereditary cardiac risk. The Plan denied your request. The Plan says that they have agreed to pay for 
81404, 81403, 81405 and 81406; however, 81404 and 81479 remain denied. The Plan argues that these 
services are part of a cardiovascular disease screening test which is provided to an individual without apparent 
signs or symptoms of cardiovascular disease. The Plan says that this kind of screening is not covered by 
Medicare and should be billed with codes 80061, 82465, 83718 and/or 84478. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the services at issue were not billed as a cardiovascular disease 
screening and they were provided to an enrollee with a personal history of cardiovascular disease. This means 
that the services at issue would not be considered a screening in this case. Medical records were provided to 
show that the ordering physician, who is noted to be a contracted provider, was treating the enrollee. The Plans 
denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(81404, 81479) provided on June 24, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra for the enrollee. 
 You asked the Plan to pre-approve the requested drug. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says the required step therapy criteria are not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 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 requested drug. 
Our reviewer says that the Plan requires a trial of Remicade, Inflectra, infliximab, or Simponi Aria before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is 
no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or 
likely have adverse effects for the enrollee. Coverage criteria are not met.  
 
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 requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Actemra for the enrollee.