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

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #18. 
 
You asked the Plan to pre-approve a crown. You say that tooth #18 has an existing large amalgam with 
defective margins and recurrent decay. The removal of the amalgam and excavation of the decay would be over 
50% of the tooth, and a crown is the only option to save this tooth. The Plan denied your request. The Plan says 
that tooth #18 does not meet the criteria for coverage of a crown. This service is covered only when the tooth is 
extensively decayed and/or fractured and cannot be restored with a direct restoration. 
 
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 a crown 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 a crown. Our reviewer says that the 
documentation provided meets the criteria for coverage of a crown restoration for tooth #18. Our physician 
reviewer found a review of the documentation indicates that tooth #18 has a large restoration with recurrent 
caries and a lingual fracture. The enrollee reports pain with chewing pressure which indicates a cracked tooth. 
It is the opinion of our reviewer that a crown is restoration is medically reasonable and necessary to protect the 
tooth from further fracture and to restore the tooth to the normal masticatory function. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a porcelain/ceramic crown (D2740) for tooth #18.  
 
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 shoulder replacement surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage for the requested replacement of the shoulder joint have not 
been met. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have undergone cortisone injection to the right shoulder, including on 12/10/21. 
However, the results from this injection are not clearly documented. Additionally, formal imaging studies are 
not provided for review, including an MRI, that demonstrates rotator cuff pathology that could benefit from the 
requested procedure. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the request for right reverse total shoulder 
arthroplasty is not medically reasonable or necessary 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve shoulder replacement surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placements (D6010) for teeth #2, #30 and #31. 
 
You asked the Plan to pre-approve dental implants. You say that these services are necessary. 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 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 
implant placements (D6010) for teeth #2, #30 and #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the advanced foot, Freedom maverick foot coded as 
L5987 and L5986. 
 
You asked the Plan to pre-approve the Freedom maverick foot. You say that the enrollee is a left below the 
knee amputee. Please see the clinic notes and AMPRO test. The Plan denied your request. The Plan says the 
requested K3 foot does not meet Medicare criteria as reasonable and necessary and is incorrectly coded.  
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 Freedom maverick foot. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was using a prosthesis that did not fit him. The provided notes 
did not describe the enrollee was able to use the prosthesis for more than simple walking and did not explain 
why the advanced features were required for this enrollee. Although the prosthesis is reasonable, the advanced 
features are not, and therefore, this request will be considered not medically necessary based on the provided 
documentation. 
 
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 Freedom maverick foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the advanced foot, Freedom maverick foot coded as L5987 and L5986.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic laboratory services (88361, 88312, 88305, 88104) 
provided on August 18, 2021. 
 
You asked the Plan to pay for diagnostic laboratory services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the services at issue were not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished 
to hospital outpatients are paid under the OPPS to the hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diagnostic laboratory services have not been met. Specifically, the records suggest that these 
services were rendered in an outpatient facility. Procedure codes 88361, 88312, 88305 and 88104 have a 
professional/technical component indicator of 1. This means that these codes have a professional and technical 
component. In this case, these codes have not been billed with the appropriate modifier to indicate that they are 
for the professional component. Payment for the technical component of these codes is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does 
not have to pay for diagnostic laboratory services (88361, 88312, 88305, 88104) provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found MRI demonstrates plausible lumbar pathology that could be causing the low back 
and hip pain. Overall, documentation is lacking regarding reasonably detailed or evidenced findings supportive 
of the spinal vertebral bodies as being the primary generators of the enrollees chronic persistent pain. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on October 11, 2021. 
 
You asked the Plan to pay for the colonoscopy. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
colonoscopy. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a colonoscopy provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic radical prostatectomy (55866). 
 
You asked the Plan to pre-approve a laparoscopic radical prostatectomy. You say that laparoscopic radical 
prostatectomy is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
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 a laparoscopic radical prostatectomy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested laparoscopic radical prostatectomy (55866) is not medically 
necessary because the enrollee does not have prostate cancer. Simple robotic retropubic laparoscopic 
prostatectomy (55831) is appropriate and medically indicated. The records appear to show the surgeon would 
like to perform this 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 a laparoscopic radical prostatectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a laparoscopic radical prostatectomy (55866).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unstable on your feet, weak, dizzy, and 
worried of falling. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on September 
4, 2021, through September 6, 2021. 
 
 
 You asked the Plan to pay for the subsequent hospital care. 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 correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99232 is not supported in the record. Specifically, the primary diagnosis code billed on 
this claim includes a code first note. Diagnosis code B94.8 is not an appropriate primary diagnosis code in this 
case. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on September 4, 2021, through September 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry by ultrasound echography (76519) 
billed for date of service July 27, 2021. 
 
You asked the Plan to pay for ophthalmic biometry by ultrasound echography. You say that the service at issue 
was a medical necessity for the enrollee. The Plan denied your request. The Plan says the provided records do 
not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76519 is "Ophthalmic biometry by ultrasound 
echography, A-scan; with intraocular lens power calculation." 
 
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 ophthalmic biometry by ultrasound echography. Our 
reviewer says that the CPT code at issue does not meet criteria for reimbursement. Our reviewer found that the medical documentation in the case record does not support that the billed service was provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ophthalmic biometry by ultrasound echography have not been met. Therefore, 
we decided that the Plan does not have to pay for ophthalmic biometry by ultrasound echography (76519) 
billed for date of service July 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that he is an appropriate candidate due to his recent 
hospitalization and numerous complications. You say that the patient's ability to regain maximum function is in 
jeopardy if denied the benefit of inpatient rehabilitation. The Plan denied your request. The Plan says care can 
safely be received in other settings. 
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you were diagnosed with hammertoe, and this is 
condition is extremely painful. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthovisc injections (J7324). 
 
You asked the Plan to pre-approve the orthovisc injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat series of hyaluronan knee injection(s) for 
patients who have responded to a prior series is considered to be reasonable and necessary when at least six 
months have elapsed since the prior series of injections. 
 
 
  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 orthovisc injections. Our reviewer 
says that the repeat injections are not medically necessary. Our physician reviewer found the record does not 
show that at least six months have elapsed since the previous injections. 
 
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 orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve orthovisc injections (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99230) provided on  by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is out of network with the Plan and the Plan has in-network 
(INN) providers available who can provide the neurologic services this member requires. 
 
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 an office visit (99230) provided on  by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Segmental gradient pressure pneumatic appliance (E0673) 
provided July 6, 2021. 
 
You asked the Plan to pay for pneumatic appliance. You say that please review attached records and process 
this for payment without further delay. The Plan denied your request. The Plan says pneumatic compression 
device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 In this case the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for Segmental 
gradient pressure pneumatic appliance (E0673) provided July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided March 
30, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that you have enclosed the physician order and 
the findings for services were performed on 03/30/2021. The Plan denied your request. The Plan says the EOB 
from the primary insurance carrier is needed to process for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
insurance on file that is the primary carrier from 11/01/2019 to 08/31/2021. As the secondary insurer, the Plan 
cannot be held responsible for the diagnostic service until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest 
(71045) provided March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.