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

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that a trial of Avastin will only prolong the enrollee's 
treatment. You say that it puts the enrollee at risk for infection. You also say that the preferred drug is not 
approved by the Food and Drug Administration for the enrollee's condition. The Plan denied your request. The 
Plan says the enrollee has not tried and failed the preferred drug, Avastin. 
 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 Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Avastin. The reviewer found that there is no indication 
that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided May 12, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that it was necessary to call 911 when you 
collapsed in your driveway after hip surgery. You feel the services received should be considered part of your 
aftercare. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on May 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that the enrollee is having trouble 
eating. The Plan denied your request. The Plan says this service is not a covered benefit and is excluded under 
the Plan's supplemental dental benefit. 
 
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 a 
mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 24, 2022. 
 
You asked the Plan to pay for the services provided. You say that the testing was necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the services are 
not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The case file shows the referring physician did not order the testing at issue. 
The medical records also do not show the physicians intent to order or have the testing provided. 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 lab testing services provided on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
admission to a long term acute care hospital. The Plan denied your request. The Plan says admission to the 
LTACH was denied as not meeting criteria, is not medically necessary, and continued acute hospital stay was 
offered, until you can discharge to a lower level of care. 
 
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 you appear to be stable and improving and should only require short term additional 
acute care hospital services that can safely be administered at the current facility until more appropriate for a 
lower level of care. You do not require services at the LTACH that are not already available 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 the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 21, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional gingivectomy or gingivoplasty (D4211) 
for the upper right quadrant. 
 
You asked the Plan to pre-approve an additional gingivectomy or gingivoplasty. You say that this service is 
necessary to obtain proper isolation for healthy margins. The Plan denied your request. The Plan says your 
benefit for the requested service has already been exhausted. 
 
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, certain limitations apply. The record 
shows that one gingivectomy or gingivoplasty (D4211) for the upper right quadrant was approved by the Plan 
on August 30, 2022, and your benefit for the requested service has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve an additional gingivectomy or gingivoplasty (D4211) for the upper right 
quadrant.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for spinal fusion surgery 
(20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that this is medically necessary. The Plan 
denied your request. The Plan says this has not been proven effective. 
 
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 bone marrow aspiration. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are not sufficient studies to support the use of bone marrow aspirate for your 
medical condition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration for spinal fusion surgery (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia on April 21, 2022. 
 
You asked the Plan to waive the coinsurance for anesthesia. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% 
coinsurance for out-of-network surgery services at outpatient hospital Outpatient hospital services. We cover 
medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an 
illness or injury. Covered services include but are not limited to services in an emergency department or 
outpatient clinic, such as observation services or outpatient surgery. The provider billed in the amount of $850 
and the allowed amount is $195.42. $195.42 x 35% = $68.40. Therefore, results in the total cost sharing 
amount of $68.40. 
 
 
 You have been asked to pay a 35% coinsurance for anesthesia. Anesthesia falls within the Outpatient hospital 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. 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 waive the coinsurance for anesthesia on April 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #29 (D2751), a pontic on tooth #29 
(D6241), and retainer crowns on tooth #28 and 30 (D6751). 
 
You asked the Plan to pre-approve a pontic and crowns. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a crown (D2751), a pontic (D6241), and retainer crowns 
(D6751) are 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 pre-approve a 
crown on tooth #29 (D2751), a pontic on tooth #29 (D6241), and retainer crowns on tooth #28 and 30 (D6751).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 19, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 19, 2022, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 19, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of September 19, 2022, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond September 19, 2022, as he was not 
a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollees condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 19, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 19, 
2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on April 15, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services are the standard of care for the 
enrollee's surgical procedure. The Plan denied your request. The Plan says the service is an inpatient only 
service. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
The file shows that the enrollee was an inpatient at the time the services were provided. 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 perfusion services provided on 
April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you need the partial because you 
will be toothless on the left side of your mouth. The Plan denied your request. The Plan says this service is not 
covered under your benefit package. 
 
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 a 
maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation with an endodontist. 
 
You asked the Plan to pre-approve an oral evaluation with an endodontist. You say that your dentist advised 
you to see an endodontist due to needing two extractions done.  You said that this is medically necessary and 
should be covered because your dentist instructed you do have it. The Plan denied your request. The Plan says 
services with an endodontist are not covered. 
 
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 an oral evaluation with an 
endodontist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 
osseous surgery (D4260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2022 billed with 
codes 81455, 81479, 81301, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 31, 2022 billed with codes 81455, 81479, 81301, and 81194.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, low intensity ultrasound, 
non-invasive (E0760). 
 
You asked the Plan to pre-approve the Osteogenesis stimulator,. You say that you have had several x-rays done 
on your fractured arm. You were given a bone stimulator is using it and it has been working. You need it for 
continued use. The Plan denied your request. The Plan says the Medicare criteria has not been met for coverage 
of the requested device 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.  
 
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 Osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is a small bone fracture and not enough time has passed to establish the 
diagnosis of nonunion on x-rays taken over 90 days. 
 
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 Osteogenesis stimulator, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flexible protective outer surface covering system 
(CPT code L5962). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the request for L5962 exceeds the enrollee's needs and cannot be covered under the Medicare 
criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. There is no medical record 
documentation provided for review that supports the assertion that the enrollee "has special needs for protection 
against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis 
beyond the level of protection that is afforded by" the approved protective cover under HCPCS code L5704. 
Therefore, we decided that the Plan does not have to pre-approve the flexible protective outer surface covering 
system (CPT code L5962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the 
enrollees benefits for the requested services have already been exhausted. 
 
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, certain limitations apply. The record 
shows the enrollees benefits for the requested services was exhausted on date of service February 25, 2022, 
and May 10, 2022. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and 
endodontic therapy (D3310).