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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L3916) provided on November 9, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do no support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided make no mention of the need for the requested item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for an orthosis (L3916) provided on November 9, 2022.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274), comprehensive oral evaluation 
(D0150), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), panoramic x-ray 
(D0330), and prophylaxis (D1110) provided on July 20, 2022, and August 2, 2022. 
 
You asked the Plan to pay for the bitewing x-rays, comprehensive oral evaluation, intraoral periapical x-rays, 
panoramic x-ray, and prophylaxis. You say that on July 20, 2022, you called and received a verbal breakdown 
stating the enrollee has preventive dental coverage. You also say that due to the misinformation that was 
provided, you are appealing these services. The Plan denied your request. The Plan says charges for dental 
related services are excluded from coverage under the enrollee's plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bitewing 
x-rays (D0274), comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), panoramic x-ray (D0330), and prophylaxis (D1110) provided on July 20, 
2022, and August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750), and periodontal scaling and root 
planing (D4341) 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 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 these services are not medically necessary. Our physician reviewer found D2750 is not medically 
necessary as there is minimal missing structure. D4341 has no noted bone loss, the four quadrants of scaling 
and root planing are not medically necessary.  
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 crown (D2750), and periodontal scaling and root planing (D4341)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the waterjet ablation (0421T). 
 
You asked the Plan to pre-approve the waterjet ablation. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
attributable to benign prostatic hyperplasia (LUTS/BPH) treatment will be considered reasonable and necessary 
when performed once in patients with the criteria listed 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 the waterjet ablation. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the estimated size of the prostate is 
higher than the required range to consider this procedure. 
 
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 waterjet ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the waterjet ablation (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hospital care received from January 12, 2022, to 
January 14, 2022. 
 
You asked the Plan to reimburse you for the hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says according to page 69 of the members Evidence of Coverage 
(EOC), when emergency services are received outside of the U.S. the member is responsible for paying for the 
services up front. The member must then submit a receipt for payment to the Plan for reimbursement. The 
member has not submitted a receipt for reimbursement at this time but has been made aware of what is 
necessary for claim reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file , the Plans rules and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the hospital care have been 
met. You have not submitted a receipt for reimbursement. Therefore, we decided that the Plan does not have to 
reimburse you for hospital care received from January 12, 2022, to January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve the partial psychiatric hospitalization. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 partial psychiatric hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient does not meet the criteria for treatment at partial hospitalization level of care and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, and was not showing any severe 
psychological or psychiatric impairment requiring this 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 the partial psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the partial psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. You say that you have trouble sleeping at night. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
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 you have a history of low back pain with radiculopathy. You underwent left sided 
transforaminal epidural steroid injections (TFESI) at the requested levels on March 1, 2023. In your follow-up 
appointment dated March 14, 2023, you were noted to have improved by 70% and to have residual pain rated at 
1 out of 10 on the visual analog scale. Your physician requested a repeat TFESI at the same levels and on the 
same side. Repeat injections are only considered medically necessary by Medicare when a prior injection 
resulted in at least 50% pain relief for at least 3 months. It has not been 3 months. Therefore, the request is 
deemed not medically reasonable and 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 an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second stage implant surgery (D6011), custom 
fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058) for tooth #13. 
 
You asked the Plan to pre-approve the dental services. 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 benefits for the requested services have already been approved for tooth #'s 11 and 12, and 
therefore, have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a second 
stage implant surgery (D6011), custom fabricated abutment (D6057), and abutment supported 
porcelain/ceramic crown (D6058) for tooth #13.
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 you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s), 
not including neurolytic substances, including needle or catheter placement, interlaminar epidural or 
subarachnoid, lumbar or sacral; with imaging guidance (62323). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because your records do not show 
documentation of concordant radiological image-based diagnostic testing. 
 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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records do not show documentation of concordant radiological image-based 
diagnostic testing supporting radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis. The review has determined that you do not meet criteria for approval of the epidural 
steroid injection. The ESI is not medically necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging 
guidance (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.  
 
Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33208 billed for July 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 33208 is not supported. 
 
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, the CPT Code Manual definition of code 33208 is insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular. 
 
We find that CPT code 33208 is not supported in the medical record. Specifically, there is no documentation of 
an insertion of new or replacement of permanent pacemaker with transvenous electrode(s); artrial and ventrical. 
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 pay for procedure code 33208 billed for July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided July 13, 
2022 to July 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided July 13, 2022 to July 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs. 
 
 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 Gel-One. Our physician reviewer found 
that the enrollee has pain related to osteoarthritis of the left knee, a diagnosis confirmed with imaging studies. 
The Plan requires a trial of Monovisc, Orthovisc, Synvisc or Synvisc One before they will approve the 
requested drug. There is no indication that the enrollee has tried and failed the required drugs. There is no 
indication that the Plan's required drugs would likely be less effective or likely have adverse effects for the 
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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
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 an intracept procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental. 
 
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 the Cologuard colorectal screening (81528) provided on 
October 2, 2022. 
 
You asked the Plan to pay for the Cologuard colorectal screening. You say that this test should be covered. The 
Plan denied your request. The Plan says there was insufficient information provided to review whether this 
service meets criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Cologuard colorectal screening have been met. Specifically, no medical records have been submitted for review. Without medical records we 
are unable to verify if coverage criteria have been met. Therefore, we decided that the Plan does not have to 
pay for the Cologuard colorectal screening (81528) provided on October 2, 2022.