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

 
We decided that the Plan does not have to pay for an immediate maxillary denture (D5130), a removable 
prosthodontic procedure (D5899), alveoloplasty (D7310), and fixed partial denture sectioning (D9120) 
provided on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the denied services were covered 
in your contract agreement with the provider. The Plan denied your request. The Plan says that an immediate 
maxillary denture (D5130), a removable prosthodontic procedure (D5899), alveoloplasty (D7310), and fixed 
partial denture sectioning (D9120) are 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 pay for an 
immediate maxillary denture (D5130), a removable prosthodontic procedure (D5899), alveoloplasty (D7310), 
and fixed partial denture sectioning (D9120) provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electrical bone-growth stimulator (E0748). 
 
You asked the Plan to pre-approve an electrical bone-growth stimulator. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone-growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone-growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 an electrical bone-growth stimulator. 
Our reviewer says that the requested item is medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a computed tomography (CT) scan of the cervical spine dated January 24, 
2023, (almost 4 months) post-surgery with noted suspected pseudoarthrosis and lucency along the right C4 
vertebral screw which encroaches upon the inferior endplate. The enrollee also is noted to be a current smoker. 
The use of bone-growth stimulation in cervical spinal fusion with known risk factors of failed fusion have been 
found efficacious. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical bone-growth stimulator have been met. Therefore, we decided that 
the Plan has to pre-approve an electrical bone-growth stimulator (E0748).  
 
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: 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 requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for congestive heart failure, pneumonia, and pleural effusion. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 pay for outpatient services (C1729, C1769, C1887, C1894, A4649, 
75743, 36015, 37241, 37242, 76937) provided on July 8, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that this service should be covered fully. 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 a 20% 
coinsurance for outpatient surgery. The plan contract states there is a $50 copayment for diagnostic procedures 
and tests.  
 
 You have been asked to pay a $33.49 copayment for diagnostic testing, and a $2,929.34 coinsurance for the 
outpatient surgery. Code 76937 falls into the diagnostic testing benefit category. The plan contract states there 
is a $50 copayment for this category of service. In this case, the Medicare allowed amount was less than $50 
($33.49) so this amount was applied instead. The remaining codes fall within the outpatient surgery category. 
The allowable amount for these services was $15,145.31. There was a 20% coinsurance ($2929.34) correctly 
applied. 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 pay for outpatient services (C1729, C1769, C1887, C1894, A4649, 
75743, 36015, 37241, 37242, 76937) provided on July 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical guidelines do not support a TTE with no intervening change in clinical status or 
physical findings. There is no supportive evidence for the medical necessity of a TTE in this enrollees clinical 
management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 21, 2022, to 
September 12, 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 the 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 
metabolic encephalopathy, or 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 the enrollee has a 
diagnosis of late onset dementia with behavioral disturbance. There was no clinical or laboratory evidence of 
metabolic encephalopathy. Our physician reviewer found the documentation does not support code G93.41.  
 
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 August 21, 2022, to September 12, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard liquid 10 percent injection solution 
(J1569). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of anti GAD 65 brainstem dysfunction. The noted 
diagnosis is not one for which coverage is available under the coverage criteria. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard liquid 10 percent injection solution (J1569).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will be at increased risk of 
hospital-acquired infection and would not have access to the therapy needed to continue to progress if the 
LTACH request is denied. You say the enrollee will continue to become even more deconditioned due to their 
prolonged hospital admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft (20930) and bone 
marrow aspirate (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve Orthofix Trinity Elite allograft and bone marrow aspirate. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says the requested 
services are experimental/investigational. 
 
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 Orthofix Trinity Elite allograft and 
bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that there is limited published, large-scale, long-term 
peer-reviewed literature that shows the requested services to be an effective and/or safe treatment for your 
pathology. Further studies are needed to demonstrate that this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthofix Trinity Elite allograft and bone marrow aspirate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Orthofix Trinity Elite allograft (20930) and 
bone marrow aspirate (20939) for a spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (CPT code 64454). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting 
of knee osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve 
radiofrequency ablation of the right knee 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve block (CPT code 64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown (D2750) 
Tooth 14 and 31. 
 
You asked the Plan to pre-approve dental services. You say that your provider said the requested services are 
medically necessary. The Plan denied your request. The Plan says there is a cavity below the bone of your 
tooth. The tooth will not last long because the cavity is below the bone. 
 
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 dental 
services 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 dental services. Our physician reviewer 
found the documentation provided was not adequate to determine if the criteria for coverage for crown 
restorations have been met. The radiographs were not of diagnostic quality. 
 
  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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve white glass with high gold content crown (D2750) Tooth 14 and 31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation of 50% relief in symptoms from the first injection. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the first injection did not provide the proper relief in this case. You 
underwent a lumbar epidural steroid injection on 9/13/2022 and reported pain relief for less than 2 months. A 
repeat epidural steroid injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the telephone office visit (99203), provided on May 19, 2020. 
 
You asked the Plan to pay for the telephone office visit. You say that the service should be covered. The Plan 
denied your request. The Plan says that you received the services out-of-network. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan did not provide the correct Evidence of Coverage (EOC). Therefore, we 
decided that the Plan has to pay for the telephone office visit (99203), provided on May 19, 2020.  
 
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 a power wheelchair (K0856) and accessories (E0951, 
E0955, E1002, E1010, E1028, E2313, E2361, E2377, E2607, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee uses a 
wheelchair daily for over four years. This system is no longer appropriate for her positioning needs, and the 
model has been discontinued. The Plan denied your request. The Plan says the enrollee does not have a 
qualifying diagnosis causing mobility limitations for a K0861. As the base code for the requested wheelchair is 
not reasonable and necessary, none of the requested accessories can be approved. The power options cannot be 
covered as it is not medically necessary to control the three requested power options through the joystick. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
musculoskeletal disease and obesity. She has trouble ambulating. Per LCD L33789, a group 3 power 
wheelchair is medically necessary when mobility limitation is due to a neurological condition, myopathy, or 
congenital skeletal deformity. The enrollee does not have any of those conditions. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0856) and accessories (E0951, E0955, E1002, 
E1010, E1028, E2313, E2361, E2377, E2607, K0040).