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

 
We decided that the Plan does not have to pre-approve a crown (D2792) for tooth #3. 
 
You asked the Plan to pre-approve the crown. You say that it has been less than a year since you received the 
last crown, and you have an exposed area in your gum. The Plan denied your request. The Plan says this 
service is allowed one time in 5 calendar years. The Plan also says that you have already had this service within 
the past 5 years and have reached the 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. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, restorative crowns are limited to 1 per 
tooth every 5 years. The record shows that you received a crown (D2740) on tooth #3 on May 25, 2021 and 
your crowns benefit for tooth #3 has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a crown (D2792) for tooth #3.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the medication is for stroke prevention. The Plan 
denied your request. The Plan says Eliquis to be administered at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.  
 
 
 Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on September 21, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99152 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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
the first 15 minutes of an independent trained observer to assist in monitoring the patient's level of 
consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services rendered on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says prior authorization 
was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your records do not show that you are expected to get better at 
an LTACH or that you are ready for discharge. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can be safely administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current facility. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services.  
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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on September 29, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the referring physician has denied ordering this 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record indicates that this testing was 
not ordered by the enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (81479) provided on September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRA of the brain. 
 
You asked the Plan to pre-approve an MRA of the brain. The Plan denied your request. The Plan says an MRA 
is not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that MRA services must be reasonable and necessary 
for the diagnosis or treatment of the specific patient involved. 
 
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 MRA of the brain. Our reviewer 
says that the MRA is not medically necessary. Our physician reviewer found that the record indicates that the 
enrollee has trigeminal neuralgia. The requested test is not being performed to evaluate a condition for which 
MRA is recommended. 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 an MRA of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRA of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that your old denture does not fit. The Plan denied 
your request. The Plan says complete upper denture is covered once every 5 plan years. The Plan also says that 
the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and complete upper denture is covered 
once every 5 plan years, the frequency limit has been reached. The record shows that the Plan paid for a 
complete series x-ray that you received on October 7, 2020. Therefore, we decided that the Plan does not have 
to pre-approve a complete upper denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have 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 Prolia. Our reviewer says that this drug 
is not medically reasonable and necessary. Our physician reviewer found that you have a diagnosis of Age-
related osteoporosis without current pathological fracture. The Plan requires a trial of one intravenous 
bisphosphonate before they will approve the requested drug. The case file does not contain documentation of 
trial and failure of an intravenous bisphosphonate. In addition, the documentation does not support that an 
intravenous bisphosphonate would likely be less effective, and/or would likely have adverse effects for you 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion and treatment to be provided a tertiary 
care facility. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee received a second 
opinion at a different hospital for a craniotomy for debulking of the tumor. The provide at a network facility is 
unwilling to provide an authorization for this procedure and in the interim the enrollee's orientation and motor 
function is deteriorating. You state there was an initial second opinion done on March 2, 2022. The Plan denied 
your request. The Plan says the request for the enrollee to go out-of-Plan for consultation and treatment 
(surgery), it is not medical necessary because the care the enrollee is seeking is available to the enrollee within 
the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found a second opinion 
from an in-network provider was not completed prior to this out-of-network consultation. There was no 
indication that the available in-network provider options for neurosurgery and radiation treatment would be less 
effective or safe for the enrollee based on the provided documentation. Therefore, this request for out-of-
network second opinion and treatment will be considered not 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 the out-of-network services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve a second opinion and treatment to be provided a tertiary care facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on April 1, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee does 
not have out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on April 1, 2021, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the thorax (71250) 
provided on July 29, 2021. 
 
You asked the Plan to pay for the CT of the thorax. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 71250 and 
71260. 
 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, we have confirmed that code 71250 
is a column II code to column I code 71260. A modifier is not allowed with this code-pair to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) of the thorax (71250) provided on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have 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 Euflexxa. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Orthovisc, Synvisc, and Synvisc-One before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
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 exudative age-related 
macular degeneration with active choroidal neovascularization. He has not tried and failed the Plan's required 
drug, bevacizumab. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Lucentis 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 Lucentis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gen panel testing provided on July 2, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim billed the testing at issue with multiple codes. If a single 
procedure is performed, only code with one unit of service may be reported for the procedure. The claim was 
also billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. 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 the gen panel testing provided on July 2, 2021.