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

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that you feel that this is needed. The Plan denied 
your request. The Plan says this is not currently shown to be safe and effective for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital services 
provided from February 15, 2020, to February 26, 2020. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the principal diagnosis code 
is supported. The Plan denied your request. The Plan says the principal diagnosis code, A41.9, is not supported. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 an additional amount for the 
inpatient care. Our reviewer says that the billing of the principal diagnosis code is not supported. Our physician 
reviewer found the provided documentation does not indicate there was clinical or laboratory evidence off 
sepsis. Therefore, the reviewer found that the provided documentation did not support the billing of primary 
diagnosis code, A41.9, sepsis, unspecified organism.  
 
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 
an additional amount for the acute inpatient hospital services provided from February 15, 2020, to February 26, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (55650) provided December 11, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 55650 is not supported in the medical record. Specifically, this service is included in the 
primary procedure. This code cannot be paid separately. Based on this information, we decided that Medicare 
rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have 
to pay for surgical services (55650) provided December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and an unspecified 
periodontal procedure (D4999) provided on January 28, 2022. 
 
You asked the Plan to pay for gingival irrigation - per quadrant and an unspecified periodontal procedure. You 
say that you would like your refund back from the dental work you had done. The Plan denied your request. 
The Plan says these services have been denied due to the procedure codes not being covered under your 2022 
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. This benefit does not include 
gingival irrigation - per quadrant (D4921) and an unspecified periodontal procedure (D4999). 
 
We looked at the file, the Plans rules, and Medicares rules. Gingival irrigation - per quadrant (D4921) and an 
unspecified periodontal procedure (D4999) are not among those covered in this benefit. Therefore, we decided 
that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and an unspecified periodontal 
procedure (D4999) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation on April 13, 2022. 
 
You asked the Plan to pay for limited oral evaluation. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says according to your Evidence of Coverage on 
pages 85-87, theres no coverage for limited oral evaluations. 
 
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 limited 
oral evaluation on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns on tooth #19 and 20 (D2740). 
 
You asked the Plan to pre-approve the crowns. You say that the crowns on tooth# 19 and 20 are medically 
necessary. The Plan denied your request. The Plan says that there is not enough bone for a crown on tooth #19. 
The Plan also says the criteria regarding the root canal treatment is not met for the crown on tooth #20.  
 
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 crowns 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 crowns. Our reviewer says that the 
criteria for coverage has been met. Our physician reviewer found that on tooth #19 there is a large defective 
restoration that requires removal, and the bone support appears adequate, and the records indicates mobility of 
+1. Our physician reviewer also found that tooth #20 appears to have a root canal fill short of the apex. It 
appears that radiographically the apical portion of the canal space is calcified and the bone support appears 
adequate. Therefore, a crown restoration is medically reasonable and necessary to restore tooth #19 and tooth 
#20 to normal 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 crowns have been met. Therefore, we decided that the Plan has to pre-approve 
crowns on tooth #19 and 20 (D2740).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy visits. 
 
You asked the Plan to pre-approve 4 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 4 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, HH PT needs.  The enrollee is functioning at a level commiserate with a 
lower level of care. As such, the requested, ongoing, home health physical therapy 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 4 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family 
practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your 
request. The Plan says this device is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro myoelectric orthosis (L8702).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on December 9, 2021. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says that 
the Plan was previously billed by and paid another provider for this service. 
 
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. Specifically, the Plan has not provided documentation to support this denial. 
Therefore, we decided that the Plan has to pay for an emergency department visit provided on  
December 9, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound (76870), and vascular study (93975) provided on 
October 13, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the documentation supports that the 
procedure was performed by your provider. You also say that this claim denied as a duplicate in error. The Plan 
denied your request. The Plan says the records submitted do not indicate that two separate services were 
performed, nor are supported. 
 
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 ultrasound (76870), and vascular study 
(93975) provided on October 13, 2021. have been met. Specifically, the record shows that the Plan processed 
and paid one unit of procedure codes 76870 and 93975 each. The documentation submitted does not support 
that an additional unit of procedure codes 76870 and 93975 were rendered on the billed date of service. 
Therefore, we decided that the Plan does not have to pay for ultrasound (76870), and vascular study (93975) 
provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on March 7, 2022, by the 
out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claims processed correctly. 
 
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 and the dental services are listed as 
covered, dental service received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on March 7, 2022, by the 
out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve FreeStyle Libre CGM. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Receiver (Monitor), dedicated, for use with therapeutic 
continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pay for the Dexcom G6 CGM transmitter, receiver and sensors. You say that you have 
neuropathy which makes it painful to prick your fingers. The Dexcom was recommended by your doctor 
because you could just read your sugar level from testing it on your arm instead pricking your fingertips. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G6 CGM transmitter, receiver and 
sensors have not been met. Therefore, we decided that the Plan does not have to pay for Receiver (Monitor), 
dedicated, for use with therapeutic continuous glucose monitor system (K0554) and supply allowance used 
with a therapeutic CGM device (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter to do daily tasks on your 
own, like grocery shopping. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on December 18, 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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of adenocarcinoma, poorly differentiated, consistent with prostatic origin, based on biopsy of a urinary bladder mass. The clinical documentation does not support that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer, and has not been previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer treatment such as therapeutic chemotherapy. The documentation does not support that the FoundationOne CDx testing meets, but does not exceed the enrollee's medical need, and is at least as beneficial as existing and available medically appropriate alternatives. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on December 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that your physician approved portable oxygen so 
you can get out of the house. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert monitor. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a lot of worsening medical 
conditions. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. 
 
The item at appeal is a medical life alert system. While this item may be of benefit to you, it is not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a Life Alert monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210) provided on December 30, 2021. 
 
You asked the Plan to pay for the extractions. You say that you were told that extractions were a covered 
service. The Plan denied your request. The Plan says you have exceeded your $1,000 allowance. 
 
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 Plan covers dental 
services up to a $1,000 allowance. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows you have exceeded your 
$1,000 allowance during the processing of this claim. Therefore, we decided that the Plan does not have to pay 
for extractions (D7210) provided on December 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 you want these items due to the pain and 
swelling in your feet. 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.