Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional levels of facet joint injections (code 64495) 
provided on May 16, 2022. 
 
You asked the Plan to pay for additional levels of facet joint injections (code 64495). You say that the 
additional levels of facet joint injections (code 64495) were medically necessary. The Plan denied your request. 
The Plan says the requested additional levels of facet joint injections (code 64495) do not meet the Medicare 
LCD coverage criteria. 
 
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 pay for additional levels of facet joint injections 
(code 64495). Our reviewer says that additional levels of facet joint injections (code 64495) are not considered 
medically necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain due 
to facet joint disease and sacroiliitis. The enrollee underwent facet injections from L2 to S1 and then also had 
S2-S5 blocks on the same day. The request for additional levels exceeds utilization criteria of more than two 
levels bilaterally. Medicare does not consider performing multiple blocks on the same day as acceptable 
practice (i.e., lumbar facets and sacral lateral branch blocks). Therefore, the procedures are deemed not 
medically 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 additional levels of facet joint injections (code 64495) have not been met. 
Therefore, we decided that the Plan does not have to pay for additional levels of facet joint injections 
(code 64495) provided on May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services (99231, 99233) billed for 
dates of service from August 31, 2021, to September 1, 2021. 
 
You asked the Plan to pay for subsequent hospital care services. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 subsequent hospital care services have 
been met. Specifically, you have not provided medical documentation for dates of service from August 31, 
2021, to September 1, 2021. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care services (99231, 99233) billed for dates of service from August 31, 2021, to September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prostate artery embolization (PAE) (37243, 36245, 
36246, 36247, 36248, 75625, 75710, 75716, 75726, 76937, 99152, 99153). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 the prostate artery embolization (PAE) is not medically reasonable and necessary in this case. 
Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside 
of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding 
radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure 
rate compared with more traditional methods (eg, transurethral resection of the prostate [TURP]). 
 
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 the prostate artery embolization (PAE) (37243, 36245, 36246, 36247, 36248, 75625, 
75710, 75716, 75726, 76937, 99152, 99153).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
K0856. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee has a diagnosis of Multiple 
Sclerosis. The diagnosis alone qualifies the enrollee for a a group 3 wheelchair base, based on Medicare 
guidelines. The Plan denied your request. The Plan says the request for K0856 Group 3 power wheelchair with 
single power option is not reasonable and necessary. As the requested K0856 Group 3 Power Wheelchair with 
Single Power Option is not reasonable and necessary, none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. 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 multiple sclerosis and has been walking using a wheelchair as a 
walker. The enrollee does drop things from their hands and is reported to have some incontinence. At this time 
the enrollee is not at high risk for skin breakdown, use a catheter or have spasticity. The enrollee does not 
require an alternative means of controlling the chair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair with single power option K0856.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional fractions of radiation treatment delivery 
(77412), special radiation treatment (77470), computed tomography (CT) guidance for placement of radiation 
therapy fields (77014), and guidance for localization of target volume for delivery of radiation treatment 
(77387). 
 
You asked the Plan to pre-approve 5 additional fractions of radiation treatment delivery and related radiation 
services. You say that the records provided support the need for the services which remain in dispute. The Plan 
denied your request. The Plan says the items which remain in dispute do not meet the coverage criteria. 
 
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 5 additional fractions of radiation 
treatment delivery and related radiation services. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found more than 10 
fractions of palliative radiation for multiple myeloma is not standard for routine practice. There is no evidence 
of a plan to perform more than the 10 approved fractions and it would not be appropriate outside of exceptional 
circumstances. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional fractions of radiation treatment delivery and related radiation 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional 
fractions of radiation treatment delivery (77412), special radiation treatment (77470), computed tomography 
(CT) guidance for placement of radiation therapy fields (77014), and guidance for localization of target volume 
for delivery of radiation treatment (77387).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the injections provided from December 6, 
2022, to December 20, 2022. 
 
You asked the Plan to reduce the coinsurance for the injections. You say that you would like for the charges to 
be reprocessed at an in-network rate. 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). Your contract with the Plan clearly says that you must pay 45% 
coinsurance for out-of-network Medicare Part B prescription drugs. Your contract with the Plan also clearly 
says that you must pay the maximum out-of-pocket amount of $5,100 before services will be fully covered. 
 
You have been asked to pay $2,328.12 coinsurance, which is 45% of the allowed amount for the injection 
provided on December 6, 2022 ($5,173.59 allowed amount x 45% = $2,328.12). You have also been asked to 
pay $2,348.15 coinsurance, which is 45% of the allowed amount for the injection provided on December 13, 
2022 ($5,218.10 allowed amount x 45% = $2,348.15). You have also been asked to pay $403.73 coinsurance, 
which is less than 45% of the allowed amount because you have met your maximum out-of-pocket amount for 
the injection provided on December 20, 2022. These items/services fall within the Medicare Part B prescription 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the injections provided from 
December 6, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two implant supported crowns for tooth number 12, 13. We 
decided that the Plan does not have to pre-approve a custom fabricated abutment and implant supported crown 
for tooth number 14.  
 
You asked the Plan to pre-approve a custom fabricated abutment for tooth 14 and implant supported crowns for 
tooth numbers 12, 13 and 14. You say that you do not agree with the denial and implants are a covered benefit.  
The Plan says that your benefit for the requested items or services has already been exhausted. 
 
We decided that the Plan has to pre-approve two implant supported crowns for tooth number 12, 13.  
 
Implant supported crowns are a covered benefit, one per tooth every five years. You can find this on page 130 
of the Plans EOC. The Plan approved custom fabricated abutments for tooth number 12 and 13 on 
authorization A0230216129285. The Plan has not provided evidence that the benefit has been exhausted for 
implant supported crowns tooth number 12 and 13. Therefore, we decided that the Plan has to pre-approve two 
implant supported crowns for tooth number 12, 13.  
 
We also decided that the Plan does not have to pre-approve a custom fabricated abutment and implant 
supported crown for tooth number 14. 
 
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 items or services was exhausted on authorization A0230216129285 and 
when the Plan authorizes implant supported crowns for tooth numbers 12, 13. Therefore, we decided that the 
Plan does not have to pre-approve a custom fabricated abutment and implant supported crown for tooth number 
14.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on 
December 12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were admitted 
to the hospital once transported. 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). Your contract with the Plan clearly says that you must pay a $200 
copayment per trip, for Medicare-covered ambulance benefits.   

You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service provided on December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
January 2, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation provided on January 2, 2023. You 
say that you did not have a copayment for an ambulance transportation in the past. 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). Your contract with the Plan clearly says that you must pay a $295 
copayment per one way trip, for Medicare-covered ambulance benefits.   

You have been asked to pay a $295 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transportation provided on January 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says the requested neuropsychological testing is 
not medically necessary. 
 
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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically necessary in this case. 
Our physician reviewer found the documentation shows you claim having long-term cognitive issues. You had 
neuropsychological testing performed on December 19, 2022, which found your cognitive profile to be intact. 
The Department of Motor Vehicles has revoked your driver's license and asked that you have a re-evaluation of 
testing. Utilizing the criteria from the Medicare LCD L34646 that this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, you do not meet the criteria as you 
do not show severity of symptoms that would warrant this type of diagnostic treatment and is therefore is not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant (D6010), an abutment 
supported crown (D6058), and a bone graft (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that the services are 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 Plan's 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. Therefore, we decided that the Plan does 
not have to pre-approve a surgical placement of implant (D6010), an abutment supported crown (D6058), and a 
bone graft (D6104).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 8, 2022.
You asked the Plan to pay for procedure code 76641. You say that the records support the procedure was performed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture for 
edentulous arch  mandibular (D6111). 
 
You asked the Plan to pre-approve dental services. You say that you are getting your teeth pulled, once that is 
complete you would like to have teeth again. 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 /abutment supported 
removable denture for edentulous arch  mandibular (D6111) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6111 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
/abutment supported removable denture for edentulous arch  mandibular (D6111).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental crowns-porcelain fused to high noble metal for teeth 
number 3 and 31 (D2750 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your benefit for the requested items has already 
been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, the Plan has not provided substantive evidence that demonstrates your benefit 
for the requested items was previously exhausted. The documentation provided in this case does not indicate 
that dental crowns were provided and paid for by the Plan for teeth number 3 and 31. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-
approve dental crowns-porcelain fused to high noble metal for teeth number 3 and 31 (D2750 x 2).  
 
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.