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

 
We decided that the Plan does not have to pay for a crown (D2740) provided on September 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was necessary. The Plan 
denied your request. The Plan says your dental benefit for the year 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 dental benefit for the year was exhausted prior to receiving the claim for the date of service of 
September 26, 2022. For the dental services provided on September 27, 2022, the Plan paid $153. For the 
dental services provided on October 5, 2022, the Plan paid $47. For the year of 2022 the Plan paid $200 ($153 
paid + $47 paid) for dental services. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on August 25, 
2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740). You say that your Plan summary states you 
have $500 for comprehensive dental coverage. You also say that the crown replacement you submitted should 
be covered up to your $500 limit under the comprehensive services umbrella. The Plan denied your request. 
The Plan says this service is not covered under your contract under any normal circumstances. 
 
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 a 
porcelain/ceramic crown (D2740) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 26, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 October 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs nocturnal and daytime 
volume ventilator. You say that bi-level therapy will not work due to the severity of the enrollee's condition. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has had recurrent admissions for shortness of breath due to exacerbations of 
heart failure with preserved ejection fraction (HFpEF.)  Arterial Blood Gasses (ABGs) have been consistent 
with acute on chronic hypercapnic respiratory failure.  The enrollee has severe obesity.  A diaphragm disorder is mentioned in some notes, but there is no documentation of this in the record.  There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease.  The enrollee may benefit from bilevel positive airway 
pressure (BiPAP) during sleep as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visits provided from June 8, 
2022, to September 28, 2022. 
 
You asked the Plan to waive the copayment for podiatry office visits. You say that you disagree with the $25 
copayments per visit because you already pay $350 per visit for the skin debridement. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for per visit for Medicare-covered podiatry care.  
 
 
 You have been asked to pay a total copayment of $375 for podiatry office visits ($25 per visit x 15 visits = 
$375.00). This item/service falls within the per visit for Podiatry Services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for podiatry office visits provided from June 8, 2022, to September 28, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixteen (16) home physical therapy visits (G0151 X16). 
 
You asked the Plan to pre-approve home health services. You say that the enrollee would benefit from physical 
therapy to recover after having COVID-19. The Plan denied your request. The Plan says the Medicare rules 
have 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that there has been clinical status change; however, it is documented that you are now 
"mod/max with activities of daily living (ADLs)" while a specific change in mobility was not documented; 
thus, 16 home health physical therapy sessions would not be 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sixteen (16) home physical therapy visits (G0151 X16).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental services. You say that you have no teeth in the back, so you would 
like this request approved. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. . Dental implants are not 
covered under the Plans dental benefits. 
 
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 
dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
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 there is not enough evidence that this type of radiation therapy guidance is 
needed or effective for the enrollee's skin cancer. 
 
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 to bill for daily simple simulations (77280- also requested in this case) and/or image-guided 
radiation therapy (IGRT) for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general- 
citations below) is not necessary. Our physician reviewer states this is unfavorable as billing for daily IGRT 
which would not be furnished in accordance with accepted standards of medical practice. 
 
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 ultrasound guided radiation therapy (G6001).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve capecitabine (CPT code J8521). 
 
You asked the Plan to pre-approve the medication. You say that it was shown that patients may have prolonged 
disease control when taking capecitabine in combination with pembrolizumab. The Plan denied your request. 
The Plan says that this use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 use is supported by one of the major drug compendia or by clinical research that appears in a Centers 
for Medicare & Medicaid Services (CMS)-approved medical journal. The documentation supports that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve capecitabine (CPT code J8521).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is on a ventilator and needs 
LTACH services to wean from the ventilator while also regaining maximum level of functioning. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
safely receive the care they need in another setting. 
 
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 that admission to an LTACH is not medically necessary. The enrollee is receiving 
appropriate care at the present acute care hospital. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Rituxan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Ruxience and/or Truxima would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services. 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says that the criteria for coverage of an MRI have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the images and report from the prior MRI of 
the pelvis dated November 11, 2022, were inadequate for the purpose of accurate pre-op staging.  The notes 
confirm a second opinion regarding that scan was obtained from a second radiologist. A repeat scan is 
reasonable based upon these factors and the repeat exam will be done specifically for imaging staging of the 
rectal tumor which is known to border the anus.  Such a repeat exam may or may not require the use of a rectal 
coil for accurate staging. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on August 16, 2022, 
billed with codes 95908, 95886, 95937, and 95955. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says the denied codes are not supported. 
 
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 95908 is Nerve conduction studies; 3-4 studies. Code 
95886 is defined as Needle electromyography, each extremity, with related paraspinal areas, when performed, 
done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, 
innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 
procedure). Code 95937 is defined as Neuromuscular junction testing (repetitive stimulation, paired stimuli), 
each nerve, any 1 method. Code 95955 is defined as Electroencephalogram (EEG) during nonintracranial 
surgery (eg, carotid surgery).  
 
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 the services as billed. Our reviewer says that the 
documentation does not support the billing of these codes. Our reviewer found for code 95908, the procedure 
report described "Pedicle screw stimulation" which would not be reported with nerve conduction studies, which 
measure amplitude and latency/velocity. Therefore, this procedure cannot be verified as performed. Code 
95886 is defined as services done with nerve conduction studies, so this also cannot be verified. For code 
95937, Train of four is described in the report, which would not be reported with neuromuscular junction 
testing.  No procedure code exists for TO4, as this procedure is included in the primary neuromonitoring 
service. Lastly, code 95955 is not supported as there is no evidence of electroencephalography being done in 
the record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuromonitoring services provided on August 16, 2022, billed with codes 95908, 
95886, 95937, and 95955.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of admission. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation Facility (IRF). 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of a humerus fracture. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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 the enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs more intense rehab due to them 
constantly being in the bed and are unable to walk due to a fall. You say that the enrollee has bruising and is in 
a lot of pain. You say that a skilled nursing facility will not give the enrollee better care. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at an 
alternate level of care. 
 
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. While the medical record supports a need for physical 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 IRF admission and services.