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

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is 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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational as it has not 
been adopted as part of evidence-based algorithms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the five additional intraoral periapical x-rays (D0230 x5) and 
periodontal maintenance (D4910) provided on June 21, 2021, and July 3, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays and periodontal maintenance. You say 
that you told the provider's staff that your insurance would cover 1 examination per year and 1 basic cleaning 
every 6 months. You also say that you are being charged $230.00 plus $254.00 as revenge. The Plan denied 
your request. The Plan says your benefits for the additional intraoral periapical x-rays has been satisfied and the 
frequency limitation has been exceeded. The Plan also says that periodontal maintenance is not a covered 
expense under your dental 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, periodontal maintenance (D4910) is 
not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure 
code per calendar year. The record shows that you received six additional intraoral periapical x-rays (D0230 
x6) on June 21, 2021, one of which was covered by the Plan, and your intraoral x-rays benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the five additional intraoral periapical 
x-rays (D0230 x5) and periodontal maintenance (D4910) provided on June 21, 2021, and July 3, 2021.  
 
Your complaint about how you were treated by the staff at the provider's office is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for IV therapy provided on March 1, 2021. 
 
You asked the Plan to waive the copayment for IV therapy. You say that you did not receive the services. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for IV therapy for outpatient hospital services.  
 
The medical records show that you received IV therapy on March 1, 2021, at an outpatient hospital facility. 
Therefore, you are responsible to pay the allowed amount of $173.83, which is less than the $250 copayment.  
 
You have been asked to pay $173.83 for IV therapy. IV therapy falls within the outpatient hospital services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 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 waive the copayment for IV therapy provided on March 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried medications for 
three months and has not gotten better. The Plan denied your request. The Plan says the requested procedure is 
experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation is 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 the enrollee has benign prostatic hyperplasia and lower urinary tract symptoms that include 
weak stream, nocturia, frequency and urgency. Treatment with Tamsulosin has not been effective, but duration 
of treatment is not present in medical records. The enrollee's prostate size is 33.45 cc by ultrasound. His 
maximum flow rate is 18 cc/s. His prostate specific antigen (PSA) level is 1.4 ng/mL. The documentation 
shows that coverage criteria have not been met. Specifically, the maximum flow rate must be lower than 15 
cc/s and there must be documentation of failure, contraindication or intolerance to at least three months of 
conventional medical therapy for LUTS/BPH. Therefore, the requested services are not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transurethral waterjet ablation of the prostate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intra-articular facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve intra-articular facet joint injections. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
the requested services 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 intra-articular facet joint injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the documentation does not support repeated intra-articular facet joint 
injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intra-articular facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intra-articular facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is experimental. More research is needed to show safety 
and efficacy of the 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (22899).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient psychiatric hospital services provided from  
December 28, 2020, through January 26, 2021. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. The Plan denied your request. The Plan 
says that the inpatient level of care is not medically necessary and more appropriate for an outpatient level of 
care. 
 
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 pay for inpatient psychiatric hospital services. Our 
reviewer says that the inpatient psychiatric hospital services were medically necessary. Our physician reviewer 
found that based upon review the records provided it was expected this enrollee would improve in a reasonable 
period of time as although he did not have dangerousness to self or others, auditory or visual hallucinations, 
delusions and was not showing any aggressive behavioral issues, this enrollee did have disorganization of 
thought process. It did appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care as although he did not have dangerousness to self or 
others, he did have thought content issues. The health Plan's denial of inpatient psychiatric services appears 
inappropriate. This enrollee did appear to require inpatient mental health treatment as although he was not a 
danger to himself or others, he was showing delusional thinking and issues with thought process. It did appear 
that active treatment was taking place. It did appear that the services were reasonably expected to improve the 
enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided, for the admission of this enrollee does meet 
the criteria for acute inpatient mental health treatment as although this enrollee was not shown to be a danger to 
himself or others but was without agitation or aggression without perceptual disturbance including auditory or 
visual hallucinations, this enrollee did have issues with thought process.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric hospital services provided from 
December 28, 2020, through January 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 pay for the application of hot or cold packs (97010) provided on 
June 2, 2021. 
 
You asked the Plan to pay for the application of hot or cold packs. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this payment is included 
in the other procedures billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97010 is application of a modality to 1 or more areas; hot 
or cold packs. 
 
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status 
indicator of B meaning that payment for this service is always bundled into another procedure. Separate 
payment is not made for CPT code 97010.  
 
Based on this information, we decided that Medicare rules for coverage of the application of hot or cold packs 
have not been met. Therefore, we decided that the Plan does not have to pay for the application of hot or cold 
packs (97010) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) and three retainer crowns (D6740 x3) 
provided on June 3, 2021. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that you are qualified as a low-income 
status. You also say that you would like these services to be approved for coverage. The Plan denied your 
request. The Plan says these procedures are not covered benefits under the dental 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 pontic 
(D6245) and three retainer crowns (D6740 x3) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on March 20, 
2021. 
 
You asked the Plan to pay for the preventive procedure. You say that you spoke with a Plan representative who 
said it was okay to rebill the services under a different provider's National Provider Identifier (NPI). You also 
say that you would like this claim to be reprocessed and paid. The Plan denied your request. The Plan says this 
service is not a covered expense under the enrollee's dental 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 
preventive procedure (D1999) provided on March 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for skilled nursing facility services are not met.
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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs or documented skilled therapy needs. Services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs appear to be custodial in nature. Medicare 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged services (99417) provided on January 25, 2021. 
 
You asked the Plan to pay for prolonged services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99417 is not supported in the medical record. Specifically, this code has a status 
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of prolonged services have not been met. Therefore, 
we decided that the Plan does not have to pay for prolonged services (99417) provided on January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve wireless capsule endoscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has had a 15-millimeter elongate structure 
identified by an abdominal computed tomography scan in May 2021 that was most likely thought to be an 
arteriovenous malformation. The record provided does not establish the medical necessity and reasonableness 
of the requested service 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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wireless capsule endoscopy (91110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix, Leucovorin Calcium, and Fluorouracil. 
 
You asked the Plan to pre-approve the requested medication. The Plan denied your request. The Plan says the 
drug regimen is not being prescribed for a medically accepted indication. 
 
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 the requested medication. Our 
physician reviewer found that the enrollee has metastatic colon cancer with liver and lung metastases. The 
requested drug regimen is not FDA-approved for the enrollee's diagnosis after progressing on Vectibix at least 
twice. The requested use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported, or not 
recommended in any of the compendia. 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 the requested medication have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vectibix, Leucovorin Calcium, and Fluorouracil.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that you would like the 
plan to reconsider their denial The Plan denied your request. The Plan says the requested 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 Vertiflex Superion Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. 
The vertiflex device is experimental. More research is needed to show safety and efficacy. Therefore, the 
enrollee does not meet criteria for the requested 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.