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

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
September 22, 2021. 
 
You asked the Plan to pay for the surgical tooth extractions. You say that these extractions were medically 
necessary. The Plan denied your request. The Plan says this service is not covered under your 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, 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 extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography rendered on November 2, 2021. 
 
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 95886 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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 95886 is not supported in the medical record. Specifically, there is no documentation of 
needle electromygraphy or each extremity, complete, 5 or more muscle studies. 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 the needle electromyography rendered on November 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine disposable supplies (A0368) and other transport 
services and supplies (A0999) provided on December 29, 2021. 
 
You asked the Plan to pay for routine disposable supplies, other transport services and supplies. The Plan 
denied your request. The Plan says supplies during transport and other services should be covered under the 
blanket payment for transport and mileage. These are additional charges that should be included in the main 
charge. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay routine 
disposable supplies (A0368) and other transport services and supplies (A0999) provided on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the i-Factor Allograft device to be used during planned 
surgery. 
 
You asked the Plan to pre-approve the i-Factor Allograft. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says medical studies have not proven that the use of this 
product during spinal surgery is better than standard allograft products. 
 
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 i-Factor Allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 83-year-old female was being treated for spinal stenosis. She presented with 
persistent cervical spine pain and symptoms. She feels she is worsening. The exam reveals diffuse tenderness of the posterior neck. There is hyperreflexia of the triceps bilaterally. It is positive bilaterally. 
Strength is decreased in the bilateral grip. Triceps are at 4/5, bilateral. Biceps are at 4+/5, bilateral. The health 
plan has approved the C5-7 spine fusion procedure.   
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology.  The peer-reviewed literature supports the use of 
i-Factor in single-level fusions. The planned fusion in this case is 2 levels. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the request for i-factor allograft is 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 the i-Factor Allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the i-Factor Allograft device to be used during planned surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the zoster (shingles) vaccine (90750) provided December 28, 2021. 
 
You asked the Plan to pay for the vaccination services. You say that you had called the insurance and asked if 
the shingles shot would be covered and was told yes. The Plan denied your request. The Plan says the Shingles 
vaccine is a Part D drug which is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for the zoster (shingles) vaccine (90750) provided December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, and 81301) 
provided on June 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81275, 81276, and 81301) provided on June 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychiatric diagnostic evaluation (90791), to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the psychiatric diagnostic evaluation. You say that the service should be 
covered. The Plan denied your request. The Plan says there are in-network providers available to perform this 
service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the psychiatric diagnostic evaluation (90791), to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Daliresp 500 mcg tablet. 
 
You asked the Plan to pre-approve Daliresp. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Daliresp 500 mcg tablet.  
 Benefits for Daliresp 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bite guard provided on December 9, 2021. 
 
You asked the Plan to pay for the bite guard. You say that you feel that the services you received were not 
reported correctly and/or were not necessary. You do not know why you still have dental problems after 
receiving the dental care. The Plan denied your request. The Plan says your dental benefit made total payments 
in the amount of $1500 for services in 2021. As such, the bite guard was provided after you had reached your 
maximum benefit. 
 
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, this benefit is limited to $1500 per year, which you reached prior to the date of service at issue. Therefore, we decided that the Plan does not have 
to pay for the bite guard provided on December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya injections (J3245 x 6). 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug should be covered. The Plan denied 
your request. The Plan says drugs to be supplied by a pharmacy are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ilumya injections (J3245 x 6).  
 
Benefits for Ilumya 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #6, #7 and #21. 
 
You asked the Plan to pre-approve crowns. You say that you have several broken teeth leading to poor 
nutrition. You are not able to chew and digest your food properly which is critical to your medical condition. 
You also say it is medically necessary for you to receive these crowns. The Plan denied your request. The Plan 
says you have exhausted your maximum benefit for a crown. 
 
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 a crown per 
tooth every 60 months.  
 
We looked at the file and Medicare rules. The records show that you received a crown for tooth #6 and #7 on 
December 5, 2017. The records also show that you received a crown for tooth #21 on February 11, 2019. The 
EOC confirms you receive a crown per tooth every 60 months; therefore, you have exhausted the maximum 
benefit for this service. Based on this information, we decided that the Plan's rules for coverage of crowns have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #6, 
#7 and #21.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have knee osteoarthritis. You have 
not tried and failed the Plan's required drugs, Orthovisc, Synvisc, or Synvisc-One. The records do not show that 
the required drugs would be less effective or have adverse effects. The Supartz FX is therefore not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation and unspecified preventive procedure 
rendered on August 27, 2021. 
 
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 the services are not covered. 
 
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 
gingival irrigation and unspecified preventive procedure rendered on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
November 23, 2021. 
 
You asked the Plan to pay for dental services. You say that all the dentist in-network were not qualified. The 
Plan denied your request. The Plan says services provided out-of-network are not covered benefits. 
 
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 dental 
services when the services are provided in-network.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667). 
 
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 member does not have lymphedema extending onto 
the chest, trunk and/or abdomen. 
 
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) and segmental appliance (E0667).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has not tried and failed the required drug. The reviewer found there is no documentation 
provided indicating that the plans required drug would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99204), to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the service should be covered. The Plan denied 
your request. The Plan says there are in-network providers that can perform this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit (99204), to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of May 4, 2022. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee needs to be in the 
facility to make sure the enrollee is getting the proper medications and dosages. The Plan denied your request. 
The Plan says the denial of authorization for continued inpatient psychiatric care is correct, because the 
enrollee's condition has improved, and the enrollee is no longer a threat to self or others. 
 
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of May 4, 
2022. Our physician reviewer found based on the records provided it is not expected that the enrollee will 
improve in a reasonable period of time beyond the date in question as the enrollee did not have suicidal or 
homicidal ideation noted and had no auditory or visual hallucinations. The enrollee did not show any abnormal 
behaviors or symptoms that would require acute treatment. It does not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the date in question. 
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of May 4, 2022.