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

 
We decided that the Plan does not have to pay for the repair, intermediate, wounds of face, ears, eyelids, nose, 
lips and/or mucous membranes; 5.1 cm to 7.5 cm (12053), and excision, malignant lesion including margins, 
face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm (11643) provided on March 8, 2022. 
 
You asked the Plan to pay for the wound care. You say that the services rendered were not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the repair, intermediate, wounds of face, ears, eyelids, nose, 
lips and/or mucous membranes; 5.1 cm to 7.5 cm (12053), and excision, malignant lesion including margins, 
face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm (11643) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) for wound care x80. 
 
You asked the Plan to pre-approve HBO for wound care. You say that hyperbaric oxygen for wound care is 
medically necessary. The Plan denied your request. The Plan says hyperbaric oxygen for wound care x80 is not 
medically necessary until there is evidence that the requested therapy is improving the member's current wound 
healing. 
 
The Plan follows Medicare rules. 
 
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 HBO x80 for wound care. Our reviewer 
says that HBO x80 for wound care is not medically necessary. Our physician reviewer found that per the 
documentation, the enrollee has multiple medical problems that have resulted in wounds to the right 
middle finger as well as a below-the-knee amputation (BKA). The enrollee has had poor wound healing to the 
BKA that occurred sometime about June 14, 2022 although no definite operative report is included. Based on 
the enrollee being 2 weeks postoperatively on June 29, 2022, it is presumed that the amputation occurred on or 
about June 14, 2022. Over the last 3 months the enrollee has been receiving routine wound care with a wound 
vacuum and transition to standard wound care with wound honey application. Wound care has been through 
standard wound clinic visits and home health visits. Because of the failure of standard wound care, HBO 
therapy was recommended. This request is for treatments that normally is reserved for acute wound healing 
failures. Due to the chronicity of the wounds for this enrollee HBO is unlikely to be effective. The next step 
would be an above the knee amputation (AKA), which is not desirable. In addition, the enrollee has a current 
prosthesis for the below the knee amputation that will require revision if wound failure occurs. The enrollee has 
two wounds thereby requiring full body chamber treatment. The enrollee has made minimal progress with the 
treatments utilized primarily because the enrollee continues to abuse hand and prosthesis due to activities of 
daily living with gardening. There does not appear to be any evidence of underlying osteomyelitis that would 
mandate for a full treatment course. The review has determined that the requested hyperbaric oxygen for 
wound care does not meet the Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO x80 for wound care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve HBO for wound care x80.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 9, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing sought was medically necessary. 
The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 cancer gene panel was not billed with a single code as required. The records do not show that 
the codes billed with the -XS modifier were separate and distinct. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more to reline maxillary dentures (D5750) and does not have to 
pay to reline mandibular dentures (D5751) provided on April 26, 2022. 
 
You asked the Plan to pay more to the dental services. You say that you thought these services would be 
covered at 80%. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. The 
Plan also says that your benefit for the requested items and services 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment to reline your maxillary dentures (D5750). This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan.  
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 26, 2022. 
Therefore, we decided that the Plan does not have to pay more to reline maxillary dentures (D5750) and does 
not have to pay to reline mandibular dentures (D5751) provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 21, 2020. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 cancer gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need this to avoid malnutrition, to 
avoid gagging in your sleep, and to prevent further social anxiety. You also say that this device is medically 
necessary. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 11, 2019. Therefore, 
we decided that the Plan does not have to pre-approve maxillary partial denture (D5213) and a mandibular 
partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 4, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed without the appropriate modifier. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, the professional component requires modifier -26 for 
payment to be considered. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown 
(D2954), two pontics (D6240 x2), two retainer crowns (D6750 x2), and two simple extractions (D7140 x2). 
 
You asked the Plan to pre-approve a prefabricated post and core, pontics, retainer crowns, and simple 
extractions. The Plan denied your request. The Plan says these services are 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 a 
prefabricated post and core in addition to crown (D2954), two pontics (D6240 x2), two retainer crowns (D6750 
x2), and two simple extractions (D7140 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the documentation provided supports the need for a 
CGM. The Plan denied your request. The Plan says there is no documentation showing that the enrollee makes 
frequent adjustments to his insulin dosage based on blood sugar determinations. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the notes say that the enrollee does not 
check blood glucose levels. There is no sliding scale provided or any indication that the Humalog dose would be changed based on blood glucose levels at meals. Since the data provided does not show that the enrollee's 
insulin doses are adjusted based on blood glucose levels, the requested CGM is not considered 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 a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
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 this admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a past medical history of traumatic brain injury and is living at home 
with increasing agitation. Medical problems are stable and there are no complex nursing or rehabilitation needs.  
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been 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 Durolane. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. In this case, the patient 
has not tried and failed the required drugs. There is no documentation provided indicating that the plans 
required drugs would likely be less effective and/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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472) and surgical stent 
(D5982). 
 
You asked the Plan to pre-approve a removal of torus palatinus and surgical stent. The Plan denied your 
request. The Plan says these 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 pre-approve a 
removal of torus palatinus (D7472) and surgical stent (D5982).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections are covered when the previous 
injection directly and significantly provides improvement of the condition being treated by at least 50% of 
sustained improvement in pain relief and/or improvement in function measured from baseline using SAME 
scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found the enrollee has not 
had a 3 month or longer sustained improvement in pain relief and/or improvement in function of at least 50% 
from the previous injection. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the coronavirus test (U0003) provided on 
December 13, 2021. 
 
You asked the Plan to reimburse you for the coronavirus test. You say that the airline travel guidelines had 
updated to require a negative test within 24-hours of travel. You say that you had to pay out-of-pocket for this. 
The Plan denied your request. The Plan says routine screening tests are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare. 
 
We looked at the file and Medicare rules. This testing was required by the airline for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to reimburse you for the coronavirus test (U0003) 
provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you do not agree with the Plan not paying for this 
service. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visit provided on June 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of diagnostic or therapeutic substance(s), not 
including neurolytic substances, of the lumbar or sacral spine with imaging guidance (62623). 
 
You asked the Plan to pre-approve the epidural steroid injection.. You say that please approve the request for 
the enrollee's 3rd injection so the enrollee can be treated for the pain and be able to get back to normal 
functional status. The Plan denied your request. The Plan says repeat lumbar interlaminar ESI (Code 62323) is 
not reasonable or necessary at this time. 
 
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 epidural steroid injection. 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 chronic low back pain. The enrollee has had two epidural 
steroid injections. The first gave minimal relief. The second gave him 85% pain relief for 6 days. The LCD 
criteria requires at least 50% pain relief for 3 months after an Epidural Steroid injection.  This criteria was not 
met and therefore, the request is deemed 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve injection of diagnostic or therapeutic substance(s), not including neurolytic 
substances, of the lumbar or sacral spine with imaging guidance (62623).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant removal, by report (D6100) and consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on May 27, 2022, to June 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you needed the services due to declining health and 
your implant was detaching causing sinus issues. The Plan denied your request. The Plan says this service is 
not covered under your 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. Implant removal, by report 
and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant removal, by 
report (D6100) and consultation - diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for implant removal, by report (D6100) and consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) provided on May 27, 2022, 
to June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that pathology CPT codes 88341, 88342, 88360, were provided to a hospital inpatient. an independent 
laboratory may not bill the Medicare contractor for the technical component of a physician pathology service 
furnished to a hospital inpatient Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pathology 
services provided on July 13, 2021.