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

 
We decided that the Plan does not have to pre-approve the implantable cardiac (loop) recorder (ILR). 
 
You asked the Plan to pre-approve the ILR. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ILR. 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 no history of atrial fibrillation, nor were any significant cardiac arrhythmias 
noted on ECG monitoring. A recent randomized clinical trial found that continuous monitoring for atrial 
fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was 
not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke but 
without a known prior history of atrial fibrillation. 
 
 
 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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable cardiac (loop) recorder (ILR).
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 you would like reconsideration because the 
requested SNF care is medically necessary. The Plan denied your request. The Plan says that you do not meet 
Medicare criteria for coverage of the SNF care. 
 
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 
admission to a skilled nursing facility for inpatient rehab services is medically appropriate.  
 Our physician reviewer found you have had a significant decline in physical functioning. You do require 
skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline 
or complications. 
 
 
  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) provided 
December 20, 2021. 
 
You asked the Plan to pay for the bitewing x-ray. You say that the x-ray was necessary. The Plan denied your 
request. The Plan says you have exceeded the frequency limit for this service. 
 
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 the bitewing 
x-ray once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were 
previously covered on December 3, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the bitewing x-ray has been exceeded. Therefore, we decided that the Plan does not have to pay 
for the bitewing - single radiographic image (D0270) provided December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2750) and core buildups, including any pins when 
required (D2950) for tooth #'s 24 and 25. 
 
You asked the Plan to pre-approve crowns and core buildups. You say that it is medically necessary that you 
receive these services because you are unable to eat, chew, or even talk properly. The Plan denied your request. 
The Plan says that the prognosis of treatment appears to be poor based on the x-rays. The Plan also says that 
the provider has not submitted the required documentation to support the long-term prognosis of the requested 
treatment. 
 
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 crowns and 
core buildups 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 and core buildups. Our reviewer 
says that these services are medically reasonable and necessary. Our physician reviewer found tooth #'s 24 and 
25 have had root canal treatment. Our reviewer found that the bone support appears adequate. Our physician 
reviewer also found that the documentation provided meets the criteria for coverage for crown restorations 
(D2750) and core buildups (D2950) for tooth #'s 24 and 25. 
 
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 and core buildups have been met. Therefore, we decided that the Plan 
has to pre-approve crowns (D2750) and core buildups, including any pins when required (D2950) for tooth #'s 
24 and 25.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
cone beam computed tomography (CT) capture and interpretation with limited field of view  less than one 
whole jaw (D0364) provided November 24, 2021. 
 
You asked the Plan to pay for the limited oral exam and cone beam CT scan. You say that you would like these 
services covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for the 
limited oral exam and the cone beam CT scan is not a covered service. 
 
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 the limited 
oral exam once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on May 3, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the limited oral exam has been exceeded. Though the Plan offers dental benefits in excess of 
Medicare coverage, the cone beam CT scan is not among those covered services. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and cone beam 
computed tomography (CT) capture and interpretation with limited field of view  less than one whole jaw 
(D0364) provided November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided March 12, 2020. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you would like reimbursement for the 
x-rays. The Plan denied your request. The Plan says this service was not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral - complete series of radiographic images (D0210) provided March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic or therapeutic injection. 
 
You asked the Plan to pre-approve a diagnostic or therapeutic injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 pre-approve a diagnostic or therapeutic injection. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, 
there is no documentation of a trial and failure of physical therapy and no diagnostic imaging reports have been 
included in the medical record. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
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 diagnostic or therapeutic injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a diagnostic or therapeutic injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan stated
that this claim denied because there was no referral for the services to be performed. The records show the
referring provider, and the treating provider were both out-of-network.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers.
The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases
involving emergencies, out of area urgent care and pre-approved care.
Both the referring provider and the rendering provider are not network providers. The Plan did not pre-approve
the service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 19,2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found under Medicare guidelines; the 
request is not medically necessary because the necessity of a third level is not documented. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the electrocardiogram services provided on August 25, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
modifier is not appropriate. 
 
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. 
 
We looked at the file and the rules. The case file is lacking vital information pertaining to the services at issue. 
The appeal, claim at issue, and waiver of liability were not included in the case file. The documentation that 
was provided is not sufficient enough to confirm that the denial was appropriate. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the electrocardiogram services provided on August 
25, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration 
because this procedure is medically necessary. The Plan denied your request. The Plan says this procedure does 
not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental and more research is needed to show its 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic shoe inserts (L3000) purchased October 13, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing this bill because you feel that you 
have been cheated. Please reconsider any type of reimbursement towards these ortho inserts. 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 pay for orthopedic shoe inserts (L3000) 
purchased October 13, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for selective catheter placement services (procedure code 36215) provided 
to the enrollee on April 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the billed code is 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 36215 is "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic 
branch, within a vascular family." 
 
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. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the operative report describes a catheter 
selectively advanced from the dialysis circuit puncture beyond the peri-anastomotic segment into the inflow 
artery, and therefore this procedure code would be covered. To cite the operative report an "A5 French catheter 
was advanced into the fistula and subsequently advanced into the arterial inflow".  Per CPT guidelines, the 
arterial inflow to the dialysis circuit is considered a separate vessel.  If a more proximal arterial inflow problem 
separate from the peripheral dialysis segment is suspected, additional catheter placement and imaging required 
for adequate evaluation of the artery may be reported separately."  
 
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 have been met. Therefore, we decided that the Plan has to pay for 
selective catheter placement services (procedure code 36215) provided to the enrollee on April 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump and 
supplies. 
 
You asked the Plan to pre-approve a negative pressure wound therapy (NPWT) pump and supplies. 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. Medicare rules say that a NPWT pump and supplies are covered under 
specific circumstances. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a negative pressure wound therapy (NPWT) pump and supplies have not been met. Specifically, 
the enrollee has been using a NPWT pump for more than 4 months. Therefore, we decided that the Plan does 
not have to pre-approve a negative pressure wound therapy (NPWT) pump and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies/clinical staff time needed due to the 
public health emergency on December 13, 2021, billed with code 99072. 
 
You asked the Plan to pay for the additional supplies/services. You say that the services were medically 
necessary and should be paid. The Plan denied your request. The Plan says partial payment was made on this 
claim. However, 99072 remains denied as it is not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Code 99072 has a status indicator of "B" on the Medicare Physician Fee Schedule. This means that payment for this is bundled with other services. Based on this information, we decided that Medicare rules for coverage of the additional supplies/services have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies/clinical staff time needed due to the public health emergency on December 13, 2021, billed with code 99072.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDX test. 
 
You asked the Plan to pay for genetic testing, FoundationOne CDX test. You say that the treating physician, 
determined that ordering the F1CDx Test is medically necessary for the enrollee to assist in treatment 
decisions. The Plan denied your request. The Plan says that the records do not show that the enrollee meets the 
criteria 
 
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. Medical records were needed to substantiate the Plans denial. The medical 
records were missing from the original file. A request for information was sent to the health plan. As of the 
date of this letter, the plan has not responded to our request and/or submitted the required information. 
Therefore, we decided that the Plan has to pay for FoundationOne CDX test.  
 
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.