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

 
We decided that the Plan does not have to pre-approve a basivertebral nerve ablation at L4-S1 with computed 
tomography (CT) and magnetic resonance imaging (MRI) guidance for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a procedure not accepted as standard of medical practice would not meet the definition 
of reasonable and necessary for the diagnosis and treatment of an illness or injury. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a basivertebral nerve ablation at L4-S1 with computed tomography (CT) and magnetic 
resonance imaging (MRI) guidance for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on 
November 22, 2021. 
 
You asked the Plan to pay for home health services. You say that the RAP was submitted. The Plan denied 
your request. The Plan says no exception request was submitted to waive the 5-day requirement for filing the 
RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 22, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant for tooth #12. 
 
You asked the Plan to pre-approve an implant for tooth #12. You say that the implant is medically necessary as 
you are having trouble chewing and have only four teeth left. The Plan denied your request. The Plan says an 
implant is covered only for the purpose of supporting a complete denture and x-rays show several natural teeth 
along with a removable maxillary partial denture. 
 
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 implants 
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 implant. Our reviewer says that you do 
not meet the Plans criteria for the requested implant. Our physician reviewer found that you have a removable 
maxillary partial denture. Our reviewer found that an implant in tooth #12 is not medically necessary. 
 
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 an implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implant (code D6010) for tooth #12.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. 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 Aranesp. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Retacrit or Procrit before they will approve the requested drug. The record indicates that the enrollee has 
anemia in chronic kidney disease, stage V not on dialysis. The Food and Drug Administration has stated that 
the requested drug is indicated for the enrollee's condition. The requested medication is a new start. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (code D2740) and core build-up (code D2950) 
for tooth #21 and #23. 
 
You asked the Plan to pre-approve a crown and core build-up. You say that the caps on tooth #21, and tooth 
#23 have broken off at the gum line and, if left untreated, your teeth will rot. The Plan denied your request. The 
Plan says both services exceed the maximum count allowed per period. 
 
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 coverage of crowns and core 
buildup are limited to one procedure per tooth every five plan years. The record shows the benefit for these 
services has been exhausted for tooth #21 and #23. Therefore, we decided that the Plan does not have to pre-
approve a crown (code D2740) and core build-up (code D2950) for tooth #21 and #23.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital and can remain there until ready for discharge to a lower level of care such as in a skilled 
nursing facility. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5810) provided by a network 
provider on March 1, 2022. 
 
You asked the Plan to pay for the complete upper denture (D5810). You say that you paid $900 out-of-pocket 
for the dentures, but you were told that you would have to pay nothing. The Plan denied your request. The Plan 
says the claim was processed correctly. 
 
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 complete upper denture (D5810) is 
covered under this benefit. The record shows total charge for the dentures was $2,095. The Plan paid the 
remaining $855 of the $1,500 allowance amount, which left a member liability for $1,240. ($2,095 - $855 = 
$1,240). Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5810) 
provided by a network provider on March 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the anesthesia services provided on December 29, 2021, billed 
with code 01936. 
 
You asked the Plan to pre-approve the anesthesia services. You say that this service should not be bundled with 
any other service. The Plan denied your request. The Plan says that this is included in payment for another 
service. 
 
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. The Plan denied this claim stating that the anesthesia was incidental to another 
procedure and was not a reasonable charge. However, the file does not have any information to support what 
procedure this was incidental to. We find that the denial is not substantiated. Therefore, we decided that the 
Plan has to pre-approve the anesthesia services provided on December 29, 2021, billed with code 01936.  
 
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 a dental crown (D2740) provided on February 24, 2022. 
 
You asked the Plan to pay for a dental crown (D2740). You say that you are new to disability and did not know 
you had to call the plan for dental. You say you were in pain and the dental office told you the service would be 
covered. The Plan denied your request. The Plan says this service is 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 when performed by an out-of-network dentist. Therefore, we decided 
that the Plan does not have to pay for a dental crown (D2740) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that this procedure is required to 
make your lower dentures fit properly. The Plan denied your request. The Plan says this service is 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 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 pre-approve 
removal of torus mandibularis (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an arthrocentesis, aspiration, and/or injection of a major joint 
or bursa (20610), injections (20551, 20553), and ultrasonic guidance for needle placement (76942) billed for 
date of service October 29, 2021. 
 
You asked the Plan to pay for an arthrocentesis, aspiration, and/or injection of a major joint or bursa and related 
services. You say that you have provided medical records to support the services billed. The Plan denied your 
request. The Plan says rules for payment have not been met because the available medical record does not 
support the services billed. 
 
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 20610 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance." 
 
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 an arthrocentesis, aspiration, and/or injection of a major joint 
or bursa and related services. Our reviewer says that the CPT codes at issue do not meet criteria for payment. 
Our reviewer found that the procedure report describes procedure performed with ultrasonic guidance. CPT 
code 20610 should be reported with services performed without ultrasound guidance. Therefore, the reported 
procedure cannot be verified. CPT codes 20551 and 20553 cannot be verified as they would be inclusive to the 
incorrectly reported primary procedure 20610. When the primary procedure is reported correctly, CPT code 
76942 would be inclusive. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an arthrocentesis, aspiration, and/or injection of a major joint or bursa and 
related services have not been met. Therefore, we decided that the Plan does not have to pay for an 
arthrocentesis, aspiration, and/or injection of a major joint or bursa (20610), injections (20551, 20553), and 
ultrasonic guidance for needle placement (76942) billed for date of service October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #30 (D7953) provided on 
February 14, 2022. 
 
You asked the Plan to pay for a bone graft. You say that the plan should have better coverage options as this is 
not up to the most modern medical standards for a better quality of life. You also say you feel the company 
should do the right thing and make changes to the covered dental benefits. The Plan denied your request. The 
Plan says that a bone replacement graft (D7953) is not covered by your supplemental 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 a bone 
replacement graft on tooth #30 (D7953) provided on February 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 26, 2021, 
through December 3, 2021. 
 
You asked the Plan to pay for the home health services. You say that these claims were not processed correctly. 
The Plan denied your request. The Plan says since the RAPs for these episodes of care were submitted more 
than 30 days after the From date for the episodes, no payment may be made. 
 
The Plan must follow Medicare rules. Medicare rules say that RAPs must be filed within 5 days of the from 
date on the home health episode of care. Total payment is reduced by 1/30th for every day that the RAP is not 
timely. 
 
We looked at the file and Medicare rules. The RAPs for the episodes of care at issue were not submitted timely, and the payment was correctly reduced by 1/30th per day. Based on this information, we decided that Medicare 
rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from July 26, 2021, through December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828) endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) 
endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic 
sensor(s), any type (L5856) all lower extremity prostheses, flex-walk system (L5981). 
 
You asked the Plan to pre-approve the advanced knee and foot features. You say that the supporting 
documentation is clearly compliant with Medicare coverage criteria, and this denial should be overturned as 
expediently as possible. The Plan denied your request. The Plan says the request for a microprocessor knee and 
K3 foot exceeds the enrollee's need and does not meet Medicare criteria as reasonable and 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 advanced knee and foot features. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case, the documentation doesn't support that the enrollee is able 
to ambulate at a K3 level and therefore the upgraded knee and ankle 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 the advanced knee and foot features have not been met. Therefore, we decided 
that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance 
phase control (L5828) endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) endoskeletal 
knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (L5856) all lower extremity prostheses, flex-walk system (L5981).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services provided on August 29, 2021, billed with code 
99291-25. 
 
You asked the Plan to pay for the critical care services. You say that this is separately payable. The Plan denied 
your request. The Plan says that this is not separately payable. Payment is included with payment for the 
procedure. 
 
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 the use of modifier -25 is appropriate for separate payment in this case. The records show that the 
provider performed a full evaluation for the critically ill patient not related to the cardiopulmonary 
resuscitation. Based on this information, we decided that Medicare rules for coverage of the critical care 
services have not been met. Therefore, we decided that the Plan has to pay for the critical care services 
provided on August 29, 2021, billed with code 99291-25.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the static progressive stretch knee device, the Knee well 
Device (Current Procedural Terminology (CPT) code E1811). 
 
You asked the Plan to pre-approve the device. You say that this is the only device available that could help you 
extend your knee as you cannot straighten your leg at all. The Plan denied your request. The Plan says the 
clinical value and effectiveness of Static progressive stretch knee device, the Knee well Device in the setting of decreased mobility status post right knee arthroplasty have not been demonstrated in the peer-reviewed 
literature. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is exercise equipment. The requested device has not been shown to be 
superior to other standard treatments for the medical condition. The requested device is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the static progressive stretch knee device, the Knee well Device (Current Procedural 
Terminology (CPT) code E1811).