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

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has amyotrophic lateral 
sclerosis (ALS) with excessive salivation. The records do not show that she has tried and failed the Plan's 
required drug, Xeomin. The records do not support that the required drug would be contraindicated or less 
effective; therefore, Myobloc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Myobloc.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the complete denture - maxillary (D5110). We decided that the Plan 
does not have to pay for the surgical placement of mini implant (D6013 x4), and surgical placement of implant 
body: endosteal implant (D6010 x4). 
 
You asked the Plan to pay for the surgical placement of mini implant (D6013 x4), surgical placement of 
implant body: endosteal implant (D6010 x4), and complete denture - maxillary (D5110). You say that the 
documents have been submitted again for review to see if this problem can be resolved so that the Plan and you 
will be satisfied. The Plan denied your request. The Plan says that implants are not covered under your benefit 
package. The Plan also says that the complete upper denture is not covered because you had already met your 
maximum for dental coverage in the 2021 calendar year. 
 
We decided that the Plan has to pay for the complete denture  maxillary (D5110) provided on 
December 29, 2021. 
 
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 for the complete denture - maxillary (D5110). Specifically, the Plan did not 
provide any documentation or evidence that the $1,000 yearly coverage limit for dental services in the 2021 
calendar year had already been reached on the date of service in dispute. 
 
Therefore, we decided that the Plan has to pay for the complete denture - maxillary (D5110). 
 
We also decided that the Plan does not have to pay for the surgical placement of mini implant (D6013 
x4), and surgical placement of implant body: endosteal implant (D6010 x4). 
 
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 surgical 
placement of mini implant (D6013 x4), and surgical placement of implant body: endosteal implant (D6010 x4) 
provided on October 27, 2020, and on April 22, 2021, as they are not among those covered under this benefit.  
 
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 gradient pressure aid (sleeve and glove combination), 
custom made (S8420). 
 
You asked the Plan to pre-approve a gradient pressure aid sleeve. You say that you have a skin graft on your 
arm due to damage to the skin from your elbow to your wrist from having your arm almost ripped off. Your 
plastic surgeon ordered a compression glove for your arm, and you are requesting reconsideration because you 
definitely need it. The Plan denied your request. The Plan says the requested gradient pressure sleeve and glove 
are not a Medicare covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that code S8420 is not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the gradient pressure sleeve have not been met. Specifically, code S8420 is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a gradient pressure aid (sleeve and 
glove combination), custom made (S8420).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22855 billed for date of service August 16, 
2022. 
  You asked the Plan to pay for procedure code 22855. You say that the surgeon performed the hardware 
removal at separate levels and the services are deemed payable. You say that the documentation should be 
reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 22855 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 22855 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 22855 billed for date of service August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical total disc arthroplasty at C4-5 and C5-6 with 
Centinel ProDisc-C Vivo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested two-level cervical disc 
arthroplasty remains experimental in nature. More research is needed to support its use. The services are 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical total disc arthroplasty at C4-5 and C5-6 with Centinel ProDisc-C Vivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that this item is medically necessary. 
The Plan denied your request. The Plan says this item 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 a MyoPro orthotic device. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
patient. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted 
her quality of life. The Plan denied your request. The Plan says the request is not supported by research. 
 
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 requested services. Our physician 
reviewer found that interspinous process devices are experimental. More research is needed to show their 
safety and efficacy. Therefore, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (CPT 93306). 
 
You asked the Plan to pre-approve transthoracic echocardiography (TTE). You say that a Transthoracic 
Echocardiography (TTE) is medically necessary. The Plan denied your request. The Plan says the requested 
Transthoracic Echocardiography (TTE) does not meet the eviCore Cardiac Imaging Guidelines. 
 
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 transthoracic echocardiography (TTE). 
Our reviewer says that the requested transthoracic echocardiography (TTE) is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has a history of previous 
echocardiogram and stress test, which were unremarkable. The documentation at this time would not point to a 
change in status that would support the medical necessity of a repeat TTE. Clinical guidelines do not support 
repeating a TTE with no intervening change in clinical status or new signs, symptoms, or physical findings. In 
summary, there is no supportive evidence for the medical necessity of repeat TTE in this enrollees clinical 
management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiography (TTE) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (CPT 93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. 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. He was admitted for respiratory failure, fluid overload, and end-stage renal disease. He is now medically stable with no complex nursing or rehabilitation needs. He 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services billed with codes 97110, 97112, 97116, 
97162, 97165, 97530, and 97535 provided from July 26, 2021, to July 30, 2021. 
 
You asked the Plan to pay for therapy services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed 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. 
 
We find that CPT codes 97110, 97112, 97116, 97162, 97165, 97530, and 97535 are not supported in the 
medical record. Specifically, no medical records were submitted for review. This means the documentation 
does not include procedure notes for the therapeutic procedures provided. Based on this information, we 
decided that Medicare rules for coverage of therapy services have not been met.  Therefore, we decided that the Plan does not have to pay for therapy services billed with codes 97110, 97112, 
97116, 97162, 97165, 97530, and 97535 provided from July 26, 2021, to July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
low back and bilateral leg pain. He had extreme lateral interbody fusion (XLIF) with hardware removal, 
posterior spinal fusion, and laminectomy. There is no documentation on physical examination of three or more 
positive test results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness 
and negative provocative testing results have not been demonstrated in the peer-reviewed literature. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a dental crown (D2740) 
 
You asked the Plan to pre-approve 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 that your benefit for the requested item or 
service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a dental crown (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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95909 billed for date of service December 6, 
2021. 
 You asked the Plan to pay for procedure code 95909. You say that reconsideration is requested for medical 
necessity. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95909 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95909 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95909 billed for date of service December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s) 
Infed (iron dextran) and Venofer (iron sucrose). The Plan states there is no indication the Plan's preferred 
drug(s) would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme (CPT code Q0138).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code S2900. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S2900 billed for date of service July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 enrollee was admitted to the hospital for frequent falls and lower extremity 
cellulitis. She is now medically stable with no complex nursing or rehabilitation needs. She 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. 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 inpatient rehabilitation facility (IRF) admission and services.