Persius/hicric huggingface dataset:
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 the services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says the records do not show that the 
enrollee has complex rehabilitation needs that require frequent evaluation by a rehab 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) device 
(L8680, 64555). 
 
You asked the Plan to pre-approve the Spring PNS device. You say that the denial of r this procedure and 
unwarranted and unsupported. This procedure is medically necessary for the enrollee. The Plan denied your 
request. The Plan says there is a lack of literature evaluating long-term efficacy and adverse events associated 
with implantable PNS devices. 
 
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 Spring PNS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found implantable peripheral nerve stimulators for chronic pain are still being studied to see if this treatment is reasonable and necessary. There is one active recruiting clinical trial [The RESET Clinical 
Trial: SPRINT Peripheral Nerve Stimulation for the Treatment of Back Pain (NCT04246281)] evaluating the 
use of this device in chronic back pain. There is no documentation stating this enrollee is enrolled in a clinical 
trial. This is an experimental procedure for low back pain and therefore, the request is deemed not 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 the Spring PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) device (L8680, 64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided September 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
September 30, 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 were in an accident and are now in a lot of pain. 
You must wear a brace and are unable to walk. You need to get aid as soon as possible. The Plan denied your 
request. The Plan says you could receive care in another setting. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee clearly exceeds the CMS established 
defining criteria for a medically appropriate acute inpatient rehab admission therapy. The Plan denied your 
request. The Plan says the services are not reasonable and 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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the acupuncture treatments (97810 x 7) provided from 
October 11, 2022, through October 25, 2022. 
 
You asked the Plan to issue reimbursement 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 that you have 
exhausted the allowable benefit for these services. 
 
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. Specifically, the Plan has stated that you have exhausted the allowable benefit 
for the acupuncture services provided in this case as payment was previously issued for 18 acupuncture visits 
provided from October 26, 2022, through December 21, 2022. However, the documentation provided to our 
organization indicates that only 9 visits have been paid for by the Plan for these indicated dates of service. As 
Medicare allows 20 acupuncture visits per calendar year, the record does not demonstrate that you have 
exhausted the allowable benefit for these services. The Plan has not substantiated their denial; therefore, we 
must find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the acupuncture 
treatments (97810 x 7) provided from October 11, 2022, through October 25, 2022.  
 
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 the Fillauer Ibex HD Cat 3 prosthetic foot to be billed 
with codes L5980 and L5986. 
 
You asked the Plan to pre-approve the prosthetic foot with the requested codes. You say that you need the 
replacement prosthetic leg to be approved as soon as possible. The Plan denied your request. The Plan says the 
type of foot being requested was submitted with codes that are not valid for this type of prosthetic foot. 
 
The Plan must follow Medicare rules. Medicare rules say that the only products that can be billed with code 
L5980 must have been reviewed and approved by the PDAC to be valid.  
 
We looked at the file and Medicare rules. The requested prosthetic foot has not been assigned code L5980 by 
the PDAC. As such, payment cannot be approved for the item with these codes. Based on this information, we 
decided that Medicare rules for coverage of the prosthetic foot with the requested codes have not been met. Therefore, we decided that the Plan does not have to pre-approve the Fillauer Ibex HD Cat 3 prosthetic foot to 
be billed with codes L5980 and L5986.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service October 15, 
2022. 
 
You asked the Plan to pay for procedure code 20930. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 20930 is considered bundled and not separately 
payable. 
 
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service October 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet denervation. 
 
You asked the Plan to pre-approve facet denervation. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only two (2) levels for facet denervation can be 
covered per rolling 12 months. 
 
We looked at the file and Medicare rules. Only two regions are covered per radiofrequency session. Review of 
the file shows that five levels are being requested for facet denervation. Based on this information, we decided 
that Medicare rules for coverage of facet denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet denervation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service August 9, 
2021. 
 
You asked the Plan to pay for procedure code 99135. You say that you submitted this claim timely and it 
should be paid. The Plan denied your request. The Plan says procedure code 99135 is considered bundled and 
not separately payable. 
 
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 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0364) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a cone 
beam computed tomography (CT) scan (D0364) provided on November 8, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87798, 87481, 87640, 87801 and 87653) provided 
on December 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that these services should be 
billed with a single code. 
 
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. Specifically, the Plan has not provided a citation for the rule used to make their 
decision. We were unable to find this rule in a determination which applies to the state where these services 
were provided. The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has 
to pay for laboratory services (87798, 87481, 87640, 87801 and 87653) provided on December 9, 2022.  
 
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 comprehensive oral evaluation (D0150), intraoral 
radiographic images (D0230), and to pay more for the partial lower denture (D5214) provided by an out-of-
network provider on April 27, 2022, and May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was an in-network 
provider and you would like the dental services covered. The Plan denied your request. The Plan says your 
benefit for the comprehensive oral evaluation and intraoral radiographic images has already been exhausted. 
Also, the proper cost share was applied to the partial lower denture at an in-network benefit level. 
 
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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on the date of service of February 2, 
2022, and the record shows the Plan paid for the intraoral radiographic image (D0220) on April 27, 2022; 
therefore, your benefit for the intraoral radiographic image (D0230) was exhausted on the date of service of 
April 27, 2022. The record shows the partial lower denture was paid at an in-network benefit level with the 
total amount allowed of $2,033 and a coinsurance amount of $1,016.50 ($2,033 allowed x 50% coinsurance). 
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 pay for comprehensive oral evaluation (D0150), intraoral radiographic 
images (D0230), and to pay more for the partial lower denture (D5214) provided by an out-of-network provider 
on April 27, 2022, and May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for November 22, 2020. 
 
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 95937 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that, if nerve testing (e.g., EMG, nerve conduction 
velocity) is performed to assess the level of paralysis during anesthesia or during mechanical ventilation, the 
range of CPT codes 95851-95941 are not separately reportable. 
 
We looked at the file and Medicare rules. Billed procedure code 95937 is not separately payable because it was billed with code nerve testing on the same date of service. Therefore, we decided that the Plan does not have to 
pay for procedure code 95937 billed for November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical first x-ray, two periapical additional x-rays, 
panoramic x-ray and endodontic therapy provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that x-rays including bitewing x-rays are covered 
benefits. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 
benefits. 
 
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 the 
periapical first x-ray, two periapical additional x-rays, panoramic x-ray and endodontic therapy provided on 
December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trinity allograft. 
 
You asked the Plan to pre-approve the requested services. You say that you are in severe pain. The Plan denied 
your request. The Plan says studies have not proven this product is better than standard allograft products. 
 
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 you are being treated for radiculopathy of the cervical region. There is limited published, 
large-scale, long-term peer-reviewed literature that shows the Trinity allograft to be an effective and/or safe 
treatment for the noted pathology.   

Further studies are needed to corroborate this allograft is as effective or better than standard allograft. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the request requested Trinity allograft, in this case, 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 a Trinity allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes E2311, E2313, and E2377. 
 
You asked the Plan to pre-approve procedure codes E2311, E2313, and E2377. You say that the requested 
wheelchair and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan 
says there is not a medical need to control the power options through a joystick. 
 
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 procedure codes E2311, E2313, and 
E2377. Our reviewer says that the requested procedure codes which represent upgraded electronics are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records 
that you have 5-/5 to 5/5 upper extremity strength. The reviewer found that the documentation indicates you 
perform intermittent urinary catheterization, thus indicating you have adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches. Therefore, the reviewer found that 
the requested upgraded electronics are 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 procedure codes E2311, E2313, and E2377 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve procedure codes E2311, E2313, and E2377.