Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional units of a negative pressure wound therapy electrical 
pump and supplies (E2402, A6550). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of a monthly evaluation of the wound or evidence of 
wound healing. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found the records show that the enrollee requires additional therapy in this case. There have been regular 
evaluations of the wounds, with monthly documentation of changes. Patient clinical progress reports are 
included in the records. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve additional units of a negative pressure wound therapy electrical pump and supplies (E2402, A6550).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency routine transportation. 
 
You asked the Plan to pre-approve non-emergency routine transportation. You say that the enrollee needs to get 
to medical appointments. The Plan denied your request. The Plan says the enrollee has utilized the maximum 
number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L4-L5 epidural steroid injection (ESI). 
 
 
You asked the Plan to pre-approve an ESI. You say that you would like reconsideration because the requested 
ESI is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of radiculopathy.  In addition, the imaging does not support the 
injection level requested for pain management injections. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an L4-L5 epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), complete series of x-
rays (D0210), and unspecified preventative procedure (D1999) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not informed about the time frame 
requirements. The Plan denied your request. The Plan says comprehensive oral exams and complete series of x-
rays are each covered once every three years. You previously had these services provided on June 3, 2019, 
which is less than 3 plan years before the date in question. Therefore, these services are denied as they exceed 
the frequency limitations of your benefit. The unspecified preventative procedure is not a covered service. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover 
services or codes that are not listed in the dental benefits chart section of the contract. The Plan can cover one 
full mouth/complete x-ray set every 3 years and one comprehensive exam every 3 plan years. 
 
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 or are requested in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150), 
complete series of x-rays (D0210), and unspecified preventative procedure (D1999) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the implant (D6010), interim implant abutment 
placement (D6051), and unspecified preventive service (D1999) provided on December 21, 2021. 
You asked the Plan to reimburse you for the dental services. You say that you should be reimbursed for the 
services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The 
Plan also says that payment cannot be made to a provider that has opted out of Medicare. 
 
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 reimburse you for 
the implant (D6010), interim implant abutment placement (D6051), and unspecified preventive service 
(D1999) provided on December 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional services performed by a qualified physical 
therapist (G0151). 
 
You asked the Plan to pre-approve additional physical therapy services. You say that additional skilled therapy 
is necessary for the enrollee. The Plan denied your request. The Plan says these services are not medically 
necessary. 
 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional physical therapy services. 
Our reviewer says that the requested, ongoing, home health physical therapy services are not medically 
necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled therapy 
needs. Our physician reviewer also found that the enrollee is functioning at a level commiserate with a lower 
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 additional physical therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional services performed by a qualified physical therapist 
(G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes a microprocessor, sensors, all 
components, and accessories, custom fabricated myoelectric orthoses (L8702). 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that the 
requested device is medically necessary. The Plan denied your request. The Plan says the requested device is 
not medically necessary and there is insufficient evidence that the device will improve the long-term outcome 
for upper extremity weakness and hemiparesis. 
 
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 powered upper extremity range of 
motion assist device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this type of powered upper extremity 
motion device remains experimental in cases of extremity weakness. More research is needed to define long 
term outcomes and benefits. 
 
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 powered upper extremity range of motion assist device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion 
assist device, elbow, wrist, hand, finger, single or double upright(s), includes a microprocessor, sensors, all 
components, and accessories, custom fabricated myoelectric orthoses (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87581, 
87631, 87640, 87798) provided on June 23, 2021. 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was billed with the office POS code, 
but the records show that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87486, 87496, 87498, 87532, 87581, 87631, 87640, 87798) provided 
on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100) provided on August 26, 2021. 
 
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on August 26, 2021. Please 
note, you are not responsible for this amount. You have a $0 responsibility for these services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta (J0490). 
 
You asked the Plan to pre-approve Benlysta. You say that you believe Benlysta is appropriate and medically 
necessary for this enrollee, and you would like it to be reconsidered for coverage. The Plan denied your 
request. The Plan says the use of this drug is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Benlysta. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of Systemic lupus 
erythematosus, antibody negative, and without evidence of lupus nephritis. Our reviewer found that the Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our 
physician reviewer also found that the Medicare approved drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. 
 
 
 
 
 
 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Benlysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Benlysta (J0490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
December 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you tooth was falling apart. You say that you 
needed the procedure. You say that you were never notified that you did not have extra dental coverage. You 
also say that this should not have been denied. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
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 crown and core build up are not 
among those covered under this benefit. Additionally, the Annual Notice of Changes for 2021 shows that the 
optional dental coverage available in 2020 was no longer available in 2021. Therefore, we decided that the Plan 
does not have to pay for the crown (D2740) and core build up (D2950) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) and occlusal adjustment - limited (D9951) provided January 7, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test and occlusal adjustment. You say that it was 
not explained to you that partials are considered dentures. The Plan denied your request. The Plan says these 
services are 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 pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431) and occlusal adjustment - limited 
(D9951) provided January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot provided on December 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were unable to obtain pre-authorization. The 
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to pay for the item at issue. Therefore, we decided that the Plan 
does not have to pay for the walking boot provided on December 19, 2021, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from September 26, 
2021, to September 29, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of admission is counted for billing 
purposes, but the date of discharge or death is not. 
 
We looked at the file and Medicare rules. Per the billed claim the admission date for inpatient services was 
entered as September 26, 2021, and the discharge date was September 29, 2021, which equals 3 inpatient days 
of service, however, 2 units of inpatient days were billed. The length of stay in the statement covers period, 
from-through dates does not equal the total days for accommodations revenue code.  Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from 
September 26, 2021, to September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 skilled nursing home health visits. 
 
You asked the Plan to pre-approve home health services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says the requested care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy.  A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health care is not medically reasonable and necessary. Our physician reviewer 
found based on the documentation provided, the Plans denial should be upheld.  The enrollee does not have 
documented skilled nursing needs. As such, the requested home health skilled nursing services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 skilled nursing home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) provided on October 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had a very uncomfortable toothache. You 
say that this evaluation was covered. You say that you went to the dentist for a routine cleaning and x-rays. 
You say that this was not covered. You also say that you have only used $410 of your $2,000 dental allotment. 
The Plan denied your request. The Plan says the frequency limit has been exceeded. 
 
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 and oral exams are covered once per 
year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation 
that you received on February 11, 2021. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related accessories 
provided on November 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that the equipment is not part of the surgical 
facilities treatment. The Plan denied your request. The Plan says the claim was billed with the incorrect place 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  The file shows that the enrollee received the services at issue at an ambulatory surgical center. We looked at 
the file and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility 
for services furnished to a beneficiary. The facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. This service was provided via 
arrangement of the facility. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility. 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 pneumatic compression device and related accessories provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from October 6, 2021, to 
November 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee is being treated for chronic low 
back pain. The Plan denied your request. The Plan says the service must be provided by a legally qualified 
physician practicing within the scope of their license. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  
 
We looked at the file and Medicare rules. The records do not show that the acupuncture services were furnished 
under the supervision of a physician, PA, NP, or CNS. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided from October 6, 2021, to November 29, 2021.