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

 
We decided that the Plan does not have to pre-approve treatment with Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-
label and not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Darzalex Faspro. Our reviewer says 
that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has a diagnosis of newly diagnosed multiple myeloma, not in remission. The FDA has not 
stated that the requested drug, to be used in combination with bortezomib and dexamethasone, is indicated for 
the enrollee's condition. The Medicare-approved cancer-drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare-approved 
cancer journals has been submitted for review.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Darzalex Faspro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), a pontic (D6245), and retainer 
crown (D6740) for tooth #18, #19, and #20 provided on August 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were necessary, and you 
would like the Plan to cover the dental services. The Plan denied your request. The Plan says the claim was 
reprocessed and your annual dental benefit maximum 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 your annual dental benefit was exhausted on the date of service of August 21, 2022. Prior to the date of 
service, the total amount the Plan paid for dental services was $828. After the Plan reprocessed the claim for 
the date of service the total amount the Plan paid for the dental services on the date of service was $2,172. The 
total amount the Plan paid for dental services for the year was $3,000 ($828 prior paid + $2,172 paid). 
Therefore, we decided that the Plan does not have to pay for the core buildup (D2950), a pontic (D6245), and 
retainer crown (D6740) for tooth #18, #19, and #20 provided on August 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zephyr valve procedure (316474, 31651) and related 
inpatient admission. 
 
You asked the Plan to pre-approve a Zephyr valve procedure with inpatient admission. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
request is not medically 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 a Zephyr valve procedure with inpatient 
admission. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the enrollee has moderate chronic obstructive pulmonary 
disease (COPD) with forced expiratory volume (FEV) of 63 percent of predicted. The clinical studies of the 
requested service did not include patients with FEV greater than 50 percent predicted. The enrollee therefore 
does not meet the inclusion criteria for the requested treatment. 
 
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 Zephyr valve procedure have not been met. Because the base procedure 
cannot be approved, the related inpatient admission cannot be approved. Therefore, we decided that the Plan 
does not have to pre-approve a Zephyr valve procedure (316474, 31651) and related inpatient admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services provided out-of-network require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on August 4, 2022, by 
an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a spinal cord stimulator implant have 
been met. Specifically, medical records were requested but not received. Medical necessity is not able to be 
established without this documentation. Therefore, we decided that the Plan does not have to pre-approve a 
spinal cord stimulator implant.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 17, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large-volume, long-term, peer-reviewed outcome studies to support the use of this device for the 
enrollees 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital services provided by an out-of-network provider 
on August 19, 2021, to August 31, 2021. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says that these services have been correctly denied. 
 
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 has failed to provide a complete case file, including medical records. 
Therefore, we decided that the Plan has to pre-approve inpatient hospital services provided by an out-of-
network provider on August 19, 2021, to August 31, 2021.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 9, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
member was in hospice on this date of service. Traditional Medicare pays for hospice services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the patient had multiple 
exams on this date of service. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RestoreX therapy device. 
 
You asked the Plan to pre-approve a RestoreX therapy device. You say that your urologist prescribed this 
device for you for the problem you are having. The Plan denied your request. The Plan says the documentation 
does not support that the requested device is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
support that this device is medically necessary. The Plan attempted to request these medical records on various 
occasions with no response. Based on this information, we decided that Medicare rules for coverage of a 
RestoreX therapy device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
RestoreX therapy device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic 
radiographic imaging (D0330) provided by a participating provider on August 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not remember getting the panoramic x-
ray and you needed these services because you have TMJ pain. The Plan denied your request. The Plan says 
your benefit for the requested item or 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 your benefit for the requested item or service was exhausted on date of service May 17, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic 
radiographic imaging (D0330) provided by a participating provider on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive pre-diagnostic (D0431), diagnostic casts (D0470), 
periodontal scaling & root planing-4 or more teeth per quadrant (D4341) xs 2, periodontal scaling & root 
planing-1 to 3 teeth per quadrant (D4342) xs 2, gingival irrigation-per quadrant (D4921) xs 8, periodontal 
maintenance (D4910), topical application of fluoride, varnish (D1206), and fixed partial denture sectioning 
(D9120).  
  We decided that the Plan does not have to pay more for extraction erupted tooth or exposed root (D7140) x's 2 
and immediate mandibular partial denture-resin base (including any conventional clasps, rests and teeth) 
(D5222). 
 
You asked the Plan to pay for dental services. You say that you called and were told these services would be 
covered. The Plan denied your request. The Plan also says some of the services are not covered under your 
Plan. The Plan also says you are responsible for any charged amount above the Plans cost-sharing amount.  
 
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. Adjunctive pre-diagnostic 
(D0431), diagnostic casts (D0470), periodontal scaling & root planing-4 or more teeth per quadrant (D4341) 
xs 2, periodontal scaling & root planing-1 to 3 teeth per quadrant (D4342) xs 2, gingival irrigation-per 
quadrant (D4921) xs 8, periodontal maintenance (D4910), topical application of fluoride, varnish (D1206), 
and fixed partial denture sectioning (D9120) are not covered under the Plans dental benefits. 
 
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 
adjunctive pre-diagnostic (D0431), diagnostic casts (D0470), periodontal scaling & root planing-4 or more 
teeth per quadrant (D4341) xs 2, periodontal scaling & root planing-1 to 3 teeth per quadrant (D4342) xs 2, 
gingival irrigation-per quadrant (D4921) xs 8, periodontal maintenance (D4910), topical application of 
fluoride, varnish (D1206), and fixed partial denture sectioning (D9120). 
 
You have been asked to pay the difference between the providers charges and the Plans payment. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You have been asked to 
pay $113 which is 50% of the total charge ($226 x 50% = $113) for extraction erupted tooth or exposed root 
(D7140) x's 2.  You have been asked to pay $545.30 which is 70% of the total charge ($779 x 70%=$545.30).  
Therefore, we decided that the Plan does not have to pay more for extraction erupted tooth or exposed root 
(D7140) x's 2 and immediate mandibular partial denture-resin base (including any conventional clasps, rests 
and teeth) (D5222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a root canal provided by an out-of-network provider on 
June 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you verified you would only owe 50%. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a root canal provided by an out-of-network 
provider on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
12, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by a participating provider on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to have five extractions. The Plan 
denied your request. The Plan says your benefit for the requested item or 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 your benefit for the requested item or service was exhausted on date of service July 29, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by a participating provider on August 22, 2022.