Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee is making steady progress 
with their current therapy and should be able to continue. The Plan denied your request. The Plan says 
continued physical therapy is not medically necessary for this enrollee, whose treatment and further gains can 
be met by a home exercise program and medical re-evaluation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
enrollee has had prior extensive physical therapy and the documentation does not reveal that the enrollee 
requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can only be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The enrollee has had instruction on a home exercise plan. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on November 10, 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 separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the stomach area. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the submitted 
records are grossly incomplete. There is a diagnosis of Gilbert syndrome which is congenital 
hyperbilirubinemia but there is no history of how the disease was discovered. Ultrasound has been referenced 
in the record as showing cystic disease in the liver but no report is in the submitted records. No recent 
abdominal physical exam is in the materials submitted. Absent all this information, the medical necessity of 
MRI of the abdomen has not been established. 
 
 
 
 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the stomach area.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried and failed one intravenous bisphosphonate therapy. 
 
 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 looked at the file, and Medicare rules. The limited records do not show that the enrollee has tried a 
bisphosphonate therapy. Based on this information, we decided that Medicare rules for coverage of Prolia have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty (D4212). 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that you need this dental 
service to be approved. The Plan denied your request. The Plan says this service is not covered under your 
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 pre-approve a 
gingivectomy or gingivoplasty (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need a night guard to help your teeth 
from shifting. The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infuse BMP-2 Allograft (CPT code 20930 x2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Infuse BMP-2 Allograft in the setting of 
posterolateral lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found BMP2 is experimental in the posterior lumbar spine. It is not Food and Drug Administration 
(FDA) approved for use there. More research is needed. 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve infuse BMP-2 Allograft (CPT code 20930 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve Vraylar. You say that the patient has been stable on this medication since 
September 9, 2019, for off label treatment for depression. The Plan denied your request. The Plan says this 
medication falls under Part D coverage. 
  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 Vraylar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and intraoral x-ray (D0220) 
provided on December 22, 2021. 
 
You asked the Plan to pay for the exam and x-ray. You say that you have coverage and do not understand why 
this claim has not been paid. The Plan denied your request. The Plan says these services are not covered by 
your dental benefit. 
 
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 
limited oral exam (D0140) and intraoral x-ray (D0220) provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on April 1, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct 
POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services (G0482) provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lidocaine patch. 
 
You asked the Plan to pre-approve a lidocaine patch. The Plan denied your request. The Plan says this 
medication falls under Part D coverage. 
  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 a lidocaine patch.  
 
Benefits for a lidocaine patch 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: 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 admission to an IRF is medically necessary for this 
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met; the 
enrollee's needs can be met in a lower level of care. 
 
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 enrollee is medically stable with no new medical issues and does not require 
close physician supervision at least three times per week for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. The enrollee does not require intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to daily therapy. 
With the enrollee's current functional level with numbness that is chronic, she is not likely to make a significant 
functional recovery in an IRF within 7-10 days. While she may benefit from physical, occupational and speech 
therapies, the enrollee's rehab services can safely be provided in a lower intensity and alternate setting such as 
in a skilled nursing facility with speech therapy available. The documentation does not support the necessity for 
admission to 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 24, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this does not meet coding standards. 
 
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 surgical services provided to the 
enrollee on August 24, 2021. have been met. Despite multiple requests, medical records needed to justify 
payment for these services was not provided by the appellant. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an urgent care visit provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that this was a simple COVID-19 
test, not an urgent care visit. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. The Plan also says that the COVID-19 treatment waiver policy expired September 
30, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records to show what services were provided. 
Without the medical records we are unable to determine if cost sharing applies. The Plan also did not provide 
documentation about the Plan's COVID-19 treatment waiver policy. Without the waiver policy documents we 
are unable to determine when the waiver expired. Therefore, we decided that the Plan has to waive the 
copayment for an urgent care visit provided on November 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one home health physical therapy visit. 
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 six visits are approved and one further is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 were admitted to the hospital on 
February 26, 2022 with weakness and discharged March 4, 2022. You began home health services on March 8, 
2022. The physical therapy note dated March 30, 2022 states you are independent with eating, standing up, and 
transfers. You are walking with a cane and assistance. You have no skilled therapy needs. After six approved 
physical therapy sessions, your level of function does not require one further visit. The one visit is 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 one home health physical therapy visit.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the resin-based composite (D2393) provided on November 10, 2021. 
 
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says that 
services rendered out-of-network are not covered. The Plan also says that your benefits for this service have 
been met. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the resin-based composite have been met. The 2021 Evidence of Coverage says that restorations 
(fillings), amalgam and/or composite, are limited to two procedure codes per calendar year. The record only 
shows that one other resin-based composite (D2393) was rendered on November 4, 2021. The documentation 
provided does not show that two restorations were provided and covered by the Plan, exhausting your 
restorations benefit. Therefore, we decided that the Plan has to pay for the resin-based composite (D2393) 
provided on November 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement (D4355), scaling and root 
planing, 4 or more teeth per quadrant (D4341), partial upper denture (D5211), scaling and root planing, 1 to 3 
teeth per quadrant (D4342), and partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the services are not listed as 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 full mouth debridement, 
scaling and root planing, and partial dentures are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve full mouth debridement (D4355), scaling and root planing, 4 
or more teeth per quadrant (D4341), partial upper denture (D5211), scaling and root planing, 1 to 3 teeth per 
quadrant (D4342), and partial lower denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Synvisc, Orthovisc, and Monovisc is required before alternatives can be 
considered. 
 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found while the record shows a trial of Synvisc, 
the plan requires a trial of Synvisc, Orthovisc, and Monovisc before alternatives can be considered. The record 
shows no trial of Orthovisc or Monovisc, or any reason these drugs would be unsafe or ineffective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).