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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
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 Intracept procedure is not medically necessary. Our physician reviewer found the 
requested Intracept procedure is considered an experimental/investigational procedure at this time.  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 admission to a SNF. Our reviewer says 
that the enrollee does not meet criteria for SNF admission. Our physician reviewer found the member has 
stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing 
and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at 
a lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. 
She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is 
at or near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient 
skilled rehab services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electronic chasis interface (L7499) custom silicone covers 
(L7499). 
 
You asked the Plan to pay for the prosthetic components. You say that upon review of the information 
provided, you request for overturn of the adverse decision and approve the code for payment. The Plan denied 
your request. The Plan says these miscellaneous codes cannot be used. These are unbundled. 
 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 L7499 is upper extremity prosthesis, not otherwise 
specified. 
 
We find that CPT code L7499 is not supported in the medical record. Specifically, HCPCS code L7499 (upper 
extremity prosthesis, not otherwise specified) must not be used for the billing of any additional features or 
components, programming, adjustment, etc. with HCPCS codes L6026, L6715, L6880, or L7007-L7009 as 
these codes are considered all-inclusive. The use of HCPCS code L7499 on initial issue, with the any of the 
above HCPCS codes is considered unbundling. Based on this information, we decided that Medicare rules for 
coverage of the prosthetic components have not been met. Therefore, we decided that the Plan does not have to 
pay for electronic chasis interface (L7499) custom silicone covers (L7499).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on December 30, 2020. 
 
You asked the Plan to pay for the replacement graft. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a bone replacement graft (D7953) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation (D9222, D9223). 
 
You asked the Plan to pre-approve sedation. You say that you want the sedation covered. The Plan denied your 
request. The Plan says deep sedation (D9222, D9223) is not covered by your dental benefits. 
 
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 deep 
sedation (D9222, D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist told you this procedure was 
medically necessary. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a bone replacement graft (D7953) provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77003 provided on 
December 17, 2021. 
 
You asked the Plan to pay for the fluoroscopic guidance services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has been billed 
without an appropriate add-on code. 
 
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 77003 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluoroscopic guidance services coded 77003 provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #1 (D7210) and extractions on tooth 
#21, 22, 23, 24, and 25 (D7140) provided on January 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 January 24, 2022. 
Therefore, we decided that the Plan does not have to pay for an extraction of tooth #1 (D7210) and extractions 
on tooth #21, 22, 23, 24, and 25 (D7140) provided on January 31, 2022.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a scrotal abscess and a foot ulcer. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on March 4, 2022. 
 
You asked the Plan to pay for hygiene instructions. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says oral hygiene instructions (D1330) are not covered by 
your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental care provided from May 9, 2018, to  November 25, 2019. 
 
You asked the Plan to pay for dental care. You say that  The Plan denied your request. The Plan says your Plan 
did not cover routine dental services in 2018 and 2019. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental care provided from 
May 9, 2018, to November 25, 2019.
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 that the enrollee is non-weight bearing and waiting 
for therapy will not allow her to heal properly and gain the function of her leg. The representative states that the 
enrollee is motivated to start therapy because she does not want to stay bedridden. The Plan denied your 
request. The Plan says authorization denied because the IRF care is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a skilled nursing facility (SNF), home with home health 
services or home with outpatient therapy. 
 
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 enrollees medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin and Hydromorphone. 
 
You asked the Plan to pre-approve Pregabalin and Hydromorphone. You say that you would like these drugs to 
be approved for coverage for the enrollee. The Plan denied your request. The Plan says Pregabalin and 
Hydromorphone are self-administered drugs, and do not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pregabalin and 
Hydromorphone.  
 
Benefits for Pregabalin and Hydromorphone may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the diagnostic casts (D0470), an occlusal 
orthotic device, by report (D7880), and the unlisted dental procedure (99999) provided on July 28, 2021. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these dental 
items/services are not a covered benefit under your contractual policy. 
 
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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the diagnostic casts (D0470), an occlusal orthotic device, by report (D7880), and the 
unlisted dental procedure (99999) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 26, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental service was received from an 
out-of-network provider and is not covered by your supplemental benefits. 
 
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 record shows that you received the dental service from an out-of-network provider. Though the Plan offers 
a dental benefit in excess of Medicare coverage, the service provided is not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture resin base (D5211) provided 
by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like approval for these services. 
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 January 4, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture resin base 
(D5211) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported removable denture (D6111). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says abutment supported removable denture (D6111) is not 
covered by your dental benefits. 
 
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 
abutment supported removable denture (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral complete 
x-ray series (D0210), topical application of fluoride (D1206), and periodontal scaling and root planing (D4342 
x 2, D4341) provided on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), intraoral complete x-ray series (D0210), topical 
application of fluoride (D1206), and periodontal scaling and root planing (D4342 x 2, D4341) provided on 
April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81162, 81314, 81317, 
81334, 81351, 81404, 81405, 81406, 81407, 81408, 81435 and 81479 provided April 23, 2021.  
You asked the Plan to pay for the laboratory services. You say that please reconsider the denial for this 
enrollee. The Plan denied your request. The Plan says there is no evidence to support that the ordering provider 
was treating this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Outreach to the provider's office the Plan was advised that this 
provider was not a part of their office. Based on this information, we decided that Medicare rules for coverage 
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded as 81162, 81314, 81317, 81334, 81351, 81404, 81405, 81406, 81407, 81408, 81435 
and 81479 provided April 23, 2021.