Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee appears to have improved with therapy but still has some 
limitations due to hip weakness and right lower extremity motor control. Further skilled therapy at this point 
does not appear to be medically indicated as outlined by Medicare guidelines to work on lower extremity 
strengthening and motor control. Further utilization of the home exercise program appears appropriate at this 
point. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve twelve (12) additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond of a crown (D2920) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the crown service. You say that you do not understand why this service would 
not be covered by your benefit. The Plan denied your request. The Plan says this service is not covered by your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for re-cement 
or re-bond of a crown (D2920) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trigger point injection (20553) 1 unit.
You asked the Plan to pre-approve the injection services. You say that say the medical records provided
support the necessity of the requested service. The Plan denied your request. The Plan says the records do not
support that the enrollee meets the Medicare coverage criteria.
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 injection services. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the physical exam does not identify where this taut muscular band was located and
the radiation of pain associated with it. 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 trigger point injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve trigger point injection (20553) 1 unit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulation system. 
 
You asked the Plan to pre-approve an implantable neurostimulation system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 implantable neurostimulation 
system. 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 compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for 
implantable neurostimulation system is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable neurostimulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantable neurostimulation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supply allowance 
provided on August 12, 2021, billed with code K0553. 
 
You asked the Plan to pay for the CGM supply allowance as billed. You say that this CGM was medically 
necessary, and all coverage criteria are met. The Plan denied your request. The Plan says the claim was not 
billed with the required modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that there are multiple modifiers which must be 
added to the CGM codes in order to be correctly billed.  
 
  
The claim reports code K0553 with no modifiers. As such, the Medicare billing rules for these items have not 
been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supply allowance provided on August 12, 2021, billed with code K0553.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture services provided from September 20, 2021, through 
October 1, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you were told this was approved, and this 
treatment has actually benefited you more than the physical therapy you were also ordered. The Plan denied 
your request. The Plan says that this service is not allowed by Medicare guidelines. 
 
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 file does not contain sufficient information to support that Medicare criteria 
are not met. While the reported diagnosis on the claim is "mononeuropathy", there is no evidence to suggest 
that this condition does not result is chronic back pain. Without additional documentation, we are unable to 
confirm that these services were provided for a noncovered condition. Therefore, we decided that the Plan has 
to pay for the acupuncture services provided from September 20, 2021, through October 1, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation (A0428).
You asked the Plan to pre-approve the ambulance transportation. You say that the ambulance transportation is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance transportation. Our
reviewer says that ambulance transportation is not medically necessary. Our physician reviewer found
documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private
car, or other type of vehicle) were contraindicated for this patient. The documentation did not support that the
patient needed the expertise, services, and lifesaving and life-sustaining equipment that only a fully-equipped
ambulance can provide.
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 ambulance transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve ambulance transportation (A0428).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. 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. 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 mental health treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. He was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. 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 mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0230 and D0220) provided 
by a participating provider on September 30, 2021. 
 
You asked the Plan to pay for intraoral radiographic images. You say that you believe that the Plan should pay 
for this. You say that this was medically necessary. The Plan denied your request. The Plan says the additional 
radiographic images are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two intraoral 
radiographic images per calendar year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of intraoral radiographic images have already been met. Therefore, we decided that the Plan does not have to pay for intraoral radiographic images (D0230 and D0220) provided by a participating provider on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and complete series of 
x-rays (D0210) provided on November 3, 2021. 
 
You asked the Plan to pay for the comprehensive exam and complete series of x-rays. You say that you had not 
seen a dentist in 18 months and do not understand how you exceeded your limits for these services. The Plan 
denied your request. The Plan says you had a previous panoramic x-ray provided in November of 2019 and a 
previous comprehensive oral exam in May 2019. Each of these services may only be covered once every three 
calendar years. Therefore, you have exceeded the frequency limitations of your 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. The Plan can cover one periodontal or comprehensive oral exam every three calendar years. The Plan can also cover one panoramic or 
diagnostic x-ray set every three calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the exam and x-ray are requested in a 
frequency that is not covered under this benefit. Documentation shows that you had a previous comprehensive 
oral exam less than three calendar years before the date in question, and you had a panoramic x-ray less than 
three years before the date in question. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral exam (D0150) and complete series of x-rays (D0210) provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on March 
18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
95938- Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin 
sites, recording from the central nervous system; in upper and lower limbs 
 
95940- Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring 
requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 
 
G0453- Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or 
nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the technical report does not include 
documentation of Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves 
or skin sites, recording from the central nervous system; in upper and lower limbs. The technical report does 
not document one on one monitoring was provided during procedures, and therefore cannot be verified. The 
technical report does not support CPT 95940, in which G0453 would be included and not separately reported. 
 
We looked at this coder'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 pay for neurophysiology services provided to the enrollee on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), and bitewing x-rays (D0274) provided on October 21, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and bitewing 
x-rays. You say that the dentist is no longer in-network, but you did not have an updated list. The Plan denied 
your request. The Plan says services performed by an OON provider are not covered because your healthcare 
plan does not have OON benefits. The Plan also says that you contacted the Plan on September 21, 2021 and 
were given network providers and benefits, but the provider you saw was not on the list of network providers 
given. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), and bitewing x-rays 
(D0274) provided on October 21, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out of network cost share for the comprehensive oral 
evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) 
provided on September 27, 2021, by the out of network provider. 
 
You asked the Plan to waive the out of network cost share for the dental services. You say that you were given 
the names of dentists who were no longer in network. You say that you found 1 in network dentist but they do 
not have good reviews. You also say that you feel you should not be responsible for the cost share. The Plan 
denied your request. The Plan says since the provider was out of network, the difference of billed amount and 
allowed, or paid, amount became your responsibility. 
 
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 and the services are listed as covered, 
out of network providers may bill you for the different between what the provider charges and the plan pays.  
 
Procedure Code Billed Amount Allowed Amount Difference Your Responsibility 
D0150 $79 $29 $50 $50 
D1110 $95 $43 $52 $52 
D0274 $73 $28 $45 $45 
D0220 $32 $11 $21 $21 
D0230 $32 $9 $23 $23 
TOTAL:    $191 
 
Therefore, we decided that the Plan does not have to waive the out of network cost share for the comprehensive 
oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) 
provided on September 27, 2021, by the out of network provider.
Appeal type: Step-Therapy
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 the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Retacrit or Procrit first. 
 
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 the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Retacrit 
or Procrit first before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
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 pay for a crown (D2780) provided by a non-participating provider on 
September 16, 2021. 
 
You asked the Plan to pay for a crown. You say that the codes were submitted correctly. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the dental service that was 
provided 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2780) provided by a non-participating provider on September 16, 2021.