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

 
We decided that the Plan has to pre-approve crown restorations (D2751) for tooth #14, #19, and #31, and a root 
canal (D3320) for tooth #20. 
 
You asked the Plan to pre-approve crown restorations and a root canal. You say that this dental work is 
medically necessary. The Plan denied your request. The Plan says that these services have been correctly 
denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers crown 
restorations and a root canal when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve crown restorations and a root canal. Our 
physician reviewer found the documentation provided meets the criteria for coverage for crown restorations 
(D2751) for teeth #'s 14, 19 and 31 and root canal treatment (D3320) for tooth #20. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown restorations and a root canal have been met. Therefore, we decided that 
the Plan has to pre-approve crown restorations (D2751) for tooth #14, #19, and #31, and a root canal (D3320) 
for tooth #20.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a history of osteoporosis. The documentation does not support that you have tried and failed 
one intravenous bisphosphonate therapy (such as zoledronic acid). The documentation does not support that 
one intravenous bisphosphonate therapy (such as zoledronic acid) would likely be less effective and/or likely 
have adverse effects. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service  
November 3, 2022. 
 You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service  
November 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of neuropsychological testing. 
 
You asked the Plan to pre-approve additional hours of neuropsychological testing. You say that this would be 
in the best interest of the standard of care, as neurodegenerative processes versus stable sequelae of damage 
have different treatment protocols and prognoses. The Plan denied your request. The Plan says the requested 
additional time is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that typically, psychological testing will require from four 
(4) to six (6) hours to perform, including administration, scoring and interpretation. Supporting documentation 
in the medical record must be present to justify greater than 8 hours per patient per evaluation. 
 
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 hours of neuropsychological 
testing. Our physician reviewer found the documentation available for review does not support medical 
necessity for the additional 9 hours of neuropsychological testing that has been requested. 
 
 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 hours of neuropsychological testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve additional hours of neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says Medicare must be 
billed directly. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for the services as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay for the 
services provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on September 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The claim billed a place of service as an ambulatory surgical center. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on September 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 You asked the Plan to pre-approve Lupron Depot. You say that the enrollee gets this injection once every six 
months, for a total of two injections per year. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drug, Eligard. 
 
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 Lupron Depot. Our reviewer says that 
the enrollee does not meet the coverage criteria for Lupron Depot. Our physician reviewer found the case file 
does not contain documentation of trial and failure of Eligard. Our reviewer also found that the documentation 
does not support that Eligard would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J9217).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 24, 2021, 
to January 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, described as 
septic encephalopathy. 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found the enrollee was a then, 88-year-old female who presented to the facility with 
reports of a change in mental status. She had been seen the previous day in the emergency department 
following a fall. The past medical history included dementia, hypertension, and hypothyroidism. She was not 
oriented to person, place, or time and was minimally verbal at baseline. The history and physical indicated that 
the patient was oriented and able to follow commands. Subsequent progress notes also indicated that the patient 
was at baseline mental status. There was no clinical or laboratory evidence of metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 24, 2021, to January 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20680. We decided that the Plan does not have to pay for 23430.   
You asked the Plan to pay for surgical services (procedure codes 20680, 23430) rendered on October 21, 2021.. 
You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 20680.  
 
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 20680 is "Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)." 
 
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 for CPT 20680. Our reviewer says that the operative 
intervention in detail cites deeper dissection showed significant subacromial adhesions. The loose anchor was 
noted anteriorly. This was removed using a rongeur. This was performed prior to the initiation of the total 
reverse shoulder. Therefore, the records do support CPT 20680 as a separate and distinct procedure from CPT 
23472. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
20680.  
 
We also decided that the Plan does not have to pay for 23430. 
 
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 23430 is "Tenodesis of long tendon of biceps." 
 
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 for CPT 23430. Our reviewer says that the records do 
not fully support that CPT 23430 was a separate and distinct procedure from CPT 23472. The operative 
intervention in detail cites deeper dissection showed significant subacromial adhesions. The biceps tendon was 
easily identified. This was tenodesed to the upper border of the pectoralis without event. However, this was 
performed essentially as a portion of initiation of the total reverse shoulder.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 23430 have not been met. Therefore, we decided that the Plan does not have to 
pay for 23430. 
 
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 Via Disc procedure. 
 
You asked the Plan to pre-approve Via Disc. You say that this procedure is supported for the enrollee. The Plan 
denied your request. The Plan says current medical literature does not consider this service to be standard 
medical treatment 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 Via Disc. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational 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 Via Disc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Via Disc procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 23430. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 23430 is bundled into payment for code 23472. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this 
case, we have confirmed that code 23430 is a column II code to column I code 23472. While this code was 
billed with modifier-59, the documentation does not support that code 23430 is a distinct procedural service 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 23430 billed for date of service November 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) rendered 
on June 20, 2022 
 
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 the documents do not support this level of care. 
 
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 99306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in order to bill CPT 99306, a 
comprehensive history, comprehensive examination and high complexity medical decision making must be 
documented. The documented history is not comprehensive, and the medical decision making is not of high 
complexity. As such, the billing of CPT 99306 is not supported. 
 
We looked at this coder'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 pay for initial nursing facility care (procedure code 99306) rendered on June 20, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on December 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance amounts for the iron administrations provided 
from April 26, 2022, to July 8, 2022. 
 
You asked the Plan to waive the coinsurance amounts for the iron administrations. You say that the iron was 
not only improperly administered, but the treatment was also ineffective. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
 
 The enrollee has been asked to pay a 20% coinsurance for the iron administrations. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance amounts for the iron administrations provided from April 26, 2022, to July 8, 2022.  
 
Your complaint about the enrollees treatments not being administered in accordance with acceptable medical 
protocols 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 special supplemental benefits for the chronically ill 
(SSBCI). 
 
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 you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. The contract with 
the Plan says that supplemental SSBCI benefits are covered when specific criteria are met.  
 
We looked at the file and the Plans rules. The file shows that no medical records were received to support that the criteria for SSBCI benefits are met. Based on this information, we decided that the Plans rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).