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

 
We decided that the Plan does not have to pre-approve Provenge. 
 
You asked the Plan to pre-approve Provenge. The drug is used to strengthen the immune system. The Plan 
denied your request. The Plan says the use is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Provenge. Our physician reviewer 
found that Provenge is not FDA-approved for the enrollees diagnosis of metastatic androgen sensitive prostate 
cancer. The use of Provenge for treatment of metastatic androgen sensitive prostate cancer is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
Although there is an off-label citation in Micromedex for use of Provenge for androgen-dependent, 
biochemically-relapsed prostate cancer, the studies that are the basis of this off-label recommendation excluded 
those with metastatic disease. The documentation does not support that the requested drug is safe and effective 
and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Provenge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Provenge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth for bridge (D6240) and a metal cap for 
bridge (D6751) for tooth #18, #19, and #20. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat properly without the dental 
procedures being done. The Plan denied your request. The Plan says the x-rays provided; it was determined that 
there is lack of adequate space for an anatomic pontic which would compromise a successful result. In addition, 
there is the presence of an established functional occlusion that precludes the medical necessity of bridge 
placement. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services 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 pre-approve the dental services. Our reviewer says 
that based on the submitted documentation there would not be medical necessity found for a false tooth for 
bridge (D6240) and a metal cap for bridge (D6751) for tooth #18, #19, and #20. Our physician reviewer found 
that in this instance there is 1 premolar missing on the lower left arch, with the molars drifting mesially such 
that the space remaining is only about 2 millimeters wide.  The minimal space would not be necessary to 
restore with a bridge as it would not add to the functional capacity of the arch. As there would be no functional 
benefit to replacing the small space remaining, there is no necessity for the procedure. The minimal space 
would not be necessary to restore with a bridge as it would not add to the functional capacity of the arch. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a false tooth for bridge (D6240) and a metal cap for bridge (D6751) for tooth #18, #19, 
and #20.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says the enrollee does not meet medical 
necessity for the requested device. The Plan says that there is no definitive evidence that the monitor, compared 
to conventional medical management and clinical monitoring, has been established as standard of care towards 
improved chronic heart failure or cardiac outcomes. 
 
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 CardioMEMS device. Our reviewer 
says that the CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with acute hypoxic respiratory failure 
due to interstitial pulmonary disease secondary to scleroderma. The record indicates that the enrollee is 
improving but still requires acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #7 and #10 provided on 
June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the dental service was a part of the 
fillings and it should be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because core buildup is not covered by the 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. 
 
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 core 
buildup (D2950) for tooth #7 and #10 provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service received on July 27, 2022 was for 
your periodic evaluation, therefore, the August 22, 2022 service should process for payment. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 27, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230 x2), and periodontal maintenance (D4910) provided on September 22, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays and periodontal maintenance. You say that you 
thought x-rays were part of the preventive care coverage. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says you did not contact the Plan prior 
to the date of service to verify benefits and provider eligibility. 
 
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 first 
intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), and periodontal 
maintenance (D4910) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) and a comprehensive oral 
evaluation (D0150) provided by a participating provider on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this amount. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 25, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) and a comprehensive 
oral evaluation (D0150) provided by a participating provider on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and extraction (D7210, 
D0330) provided on July 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the panoramic radiographic image 
(D0330) has already been exhausted. The coverage for a tooth extraction (D7210) is denied as it does not fall 
under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 01/09/2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image and extraction (D7210, 
D0330) provided on July 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure, including root planing - one to 
three contiguous teeth or tooth bounded spaces per quadrant tooth #'s 25 and 32 (D4241) provided on August 
23, 2022. 
 
You asked the Plan to pay for the gingival flap procedure, including root planing - one to three contiguous teeth 
or tooth bounded spaces per quadrant tooth #'s 25 and 32 (D4241). You say that you received an estimate from 
the dentist that (D4241) would be covered for $199.50. You also say that you received a denial for these 
services as non-covered. The Plan denied your request. The Plan says this service is 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 a gingival 
flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant 
tooth #'s 25 and 32 (D4241) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110), a fabricated abutment 
(D6057), and an implant (D6111) for tooth #22 and #27 provided on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is a qualified dentist, and the 
procedures should be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the complete upper denture, a fabricated abutment, and an implant are not covered 
by 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. Therefore, we decided that the Plan does not have to pay for a 
complete upper denture (D5110), a fabricated abutment (D6057), and an implant (D6111) for tooth #22 and 
#27 provided on June 9, 2022.
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. The Plan denied your request. The Plan says that the coverage 
criteria for admission to an IRF has not been met. 
 
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 that you have no medical complexity, and no rehabilitation nursing needs other than 
routine nursing care. While you may benefit from physical and occupational therapy, your rehabilitation needs  
 can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or home with 
services and family support. 
 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 22, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
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 procedure code 76700 billed for date of service August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 6, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 6, 2022, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses provided on October 26, 2021. 
 
You asked the Plan to pay for knee orthoses. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item rendered is not supported.  

The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered when the 
documentation shows that the enrollee has had a recent knee injury or has knee instability due to a special 
condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee orthoses provided on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman fusion plate procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says experimental procedures are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Minuteman procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman fusion plate procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 25, 2022, to May 
18, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 25, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided April 25, 2022, 
to May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2750) and an extraction (D7210) for tooth 
#3 and #21 provided on May 25, 2022, and June 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan did not pay the full amount for 
the dental services. The Plan denied your request. The Plan says your yearly dental benefit maximum has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your yearly dental benefit was exhausted on date of service June 21, 2022. Prior to the dates of service, 
the Plan made a $161.84 overpayment to the enrollee for services that were not rendered on January 09, 2021. 
For the dates of services, the Plan paid $838.16 towards the dental services. Therefore, the yearly dental benefit 
amount of $1,000 ($161.84 overpayment + $838.16 paid towards dental services) was exhausted. Therefore, we 
decided that the Plan does not have to pay more for a crown (D2750) and an extraction (D7210) for tooth #3 
and #21 provided on May 25, 2022, and June 21, 2022.