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

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the claim should have been fully paid as these 
are covered 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. This benefit includes the 
requested limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0140 on September 22, 2022; therefore, your benefit was exhausted on date of 
service September 22, 2022. Therefore, we decided that the Plan does not have to pay for limited oral 
evaluation - problem focused (D0140) provided on December 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization and ventriculography (93458). 
 
You asked the Plan to pre-approve cardiac catheterization and ventriculography. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 cardiac catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee had a stress test just over one year ago 
that was negative for ischemia, without up-sloping ST segment depressions, though the study result was 
referred to as concerning. The current echocardiogram is reviewed and is normal. The stress test could be 
repeated if desired. Guidelines do not support a need for invasive cardiac catheterization in this setting. As a 
result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollee's 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 cardiac catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve cardiac catheterization and ventriculography (93458).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 
21, 2023. 
 You asked the Plan to pre-approve SNF care after April 21, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
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 SNF care after April 21, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after April 21, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341), and office visit for observation (D9430) provided on August 11, 2022. 
 
You asked the Plan to pay for the dental codes represented by D4341 and D9430. You say that you went for 
your first routine teeth cleaning on July 27, 2022, but the dental provider stated you needed a deep clean. You 
also say that your appointment was finished in one hour and a deep clean usually takes two visits at an hour 
each. The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), and office visit for observation 
(D9430) provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided 
December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office told you that the fluoride 
treatment would be covered under your dental plan. The Plan denied your request. The Plan says your benefit 
for the topical application of fluoride varnish 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 topical application of fluoride varnish was exhausted on date of service February 2, 
2022, and June 8, 2022. The Plan has indicated that the provider wrote off the charge. Therefore, we decided 
that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided December 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the chiropractic manipulative treatments 
(98941 x 6) provided from October 14, 2022, through November 22, 2022. 
 
You asked the Plan to waive the copayments for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. 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 $20 
copayment for in-network Medicare-covered chiropractic services.  
 
  
You have been asked to pay $120 ($20 copayment x 6) for the in-network Medicare-covered chiropractic 
services provided. 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 copayments for the chiropractic manipulative 
treatments (98941 x 6) provided from October 14, 2022, through November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous durable medical equipment (DME) and the 
compression stockings identified with code A4927 and A6549 that were issued on September 12, 2022, and 
September 24, 2022. 
 
You asked the Plan to pay for the DME and the compression stockings. You say that your therapist ordered the 
specialized items, and you would like to be reimbursed for them. The Plan denied your request. The Plan says 
the compression stockings are not covered by Medicare. Also, the items were purchased from a provider who 
has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A4927 and 
A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. The rules also 
say that no Medicare payment may be made to a beneficiary for items or services provided directly by a 
physician or practitioner who has opted out of the program except in cases involving emergencies or urgently 
needed care. 
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. The services at issue in this appeal were also provided in a non-urgent, non-emergent 
situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does 
not have to pay for the miscellaneous durable medical equipment (DME) and the compression stockings 
identified with code A4927 and A6549 that were issued on September 12, 2022, and September 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve single photon emission computed tomography (SPECT) imaging 
(78832). 
 
You asked the Plan to pre-approve SPECT imaging. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says that the requested SPECT imaging is redundant. The Plan also says that the 
requested SPECT imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SPECT imaging. Our reviewer says that 
the requested SPECT imaging is considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates the enrollee has tried and failed conservative therapies. The 
reviewer found the enrollee had a magnetic resonance imaging (MRI) indicating facet disease. The reviewer 
also found that a SPECT exam is indicated to rule out infection in the disc and surrounding tissues. Therefore, 
the requested SPECT imaging is medically reasonable and 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 SPECT imaging have been met. Therefore, we decided that the Plan has to pre-
approve single photon emission computed tomography (SPECT) imaging (78832).  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation shows that the enrollee has had acute functional/clinical status change 
thus would require assessment by skilled nursing/therapy. Evaluating therapists recommend ongoing skilled 
therapy in a skilled nursing facility. Clinical documentation shows that the enrollee requires daily skilled 
services on an inpatient basis in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
  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. The Plan denied your request. The Plan says the enrollee's records 
do not support the requested services, services needed are help with self-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 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve MIS fusion of the SI joint. You say that the records support this procedure. 
The Plan denied your request. The Plan says the enrollee has not had 6 months of conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules state that MIS fusion of the SI joint is only covered if 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 pre-approve MIS fusion of the SI joint. Our 
reviewer says that the enrollee does not meet criteria for this surgery. Our physician reviewer found provided 
diagnostic studies do not corroborate SI joint pathology and the magnetic resonance imaging (MRI) of the 
lumbar spine did not rule out other plausible sources of pain generation. The enrollee has had intra-articular SI 
joint injections; however, 6 months of reasonable and comprehensive less-invasive measures have not been 
fully documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MIS fusion of the SI joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your physicians have stated that you need in-patient 
rehabilitation in order to go home safely. The Plan denied your request. The Plan says you do not have complex 
rehabilitation needs that require you to be seen 3 times per week by a rehabilitation doctor. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the 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 congestive heart failure and coronavirus infection. 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, 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 this 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of pain in this patient is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (the 
MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that this is medically necessary and the Plan is 
responsible for coverage. The Plan denied your request. The Plan says the enrollee's imaging results are not 
consistent with the inclusion criteria for the MILD procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the MILD procedure may be covered through 
CED for beneficiaries with lumbar spinal stenosis who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. You have requested enrollment in trial NCT03072927, which is a 
Medicare-approved CED study; however, this study is not currently recruiting new participants. Therefore, the 
enrollee cannot receive coverage for the MILD procedure through this CED study at this time. Based on this 
information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (the 
MILD procedure).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 78 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.