Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781), an all-lower extremity prosthesis, 
flex foot system (L5980) and an addition to lower limb prosthesis, vertical shock reducing pylon feature 
(L5988). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are medically necessary. The 
Plan denied your request. The Plan says the requested prosthesis exceeds your need. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. On 
3/16/2021, you received an advanced microprocessor foot and ankle system (L5973) which is still under 
manufacturers warranty. The treating medical PA-C progress notes do not indicate a need for a new foot. The 
L5988 is part of a foot to be paired with a complete foot. As the current foot is still under warranty the L5988 
cannot be deemed to be medically necessary. Per documentation, the physician note indicates a 
recommendation for an elevated vacuum system. The literature reviewed indicates that further research is 
needed with clinical trials that recruit larger sample sizes and report long-term outcome data for the requested 
vacuum suspension system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781), an all-lower extremity prosthesis, flex foot system (L5980) and an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the advanced foot. 
 
You asked the Plan to pre-approve the advanced foot. You say that the foot is necessary. The Plan denied your 
request. The Plan says that this is not 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 advanced foot. Our physician 
reviewer found the records are quite complete indicating the enrollee has progressed from the enrollee's initial 
K1 ambulation to a K3 level.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the advanced foot have been met. Therefore, we decided that the Plan has to 
pre-approve the advanced foot.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing with procedure code G0481 provided on 
January 10, 2022. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation provided 
supports definitive drug testing at a level supported by another code. Based on this information, we decided 
that Medicare rules for coverage of procedure code G0481 have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing with procedure code G0481 provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and are in the middle of 
treatment. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth # 27 (D7210) provided on March 15, 2022. 
 
You asked the Plan to pay for an extraction. You say that you have out-of-network dental benefits. The Plan 
denied your request. The Plan says your annual dental maximum has been exhausted. 
 
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 record shows your annual dental maximum has been exhausted. You have been asked to pay the non-
covered amount of $213 for an extraction. Therefore, we decided that the Plan does not have to pay for an 
extraction of tooth # 27 (D7210) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for three teeth. 
 
You asked the Plan to pre-approve the dental services. You say that due to possible infection, these teeth need 
to be removed. The Plan denied your request. The Plan says the services requested are not covered under the 
enrollee's supplemental 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 
removal of residual tooth roots (D7250) for three teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9630, D4342, D4341) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services (D9630, D4342, D4341) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions on tooth # 8 and 9 (D7210). 
 
You asked the Plan to pre-approve the extractions. You say that you disagree with the denial of dental services. 
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 this prior authorization. Therefore, we 
decided that the Plan does not have to pre-approve extractions on tooth # 8 and 9 (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2750) 
 
You asked the Plan to pre-approve the dental crown. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not qualify for them since your teeth do not have at least 50% bone support. 
 
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 pre-approve a 
dental crown (D2750)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #6 and 7 (D7953) and 
guided tissue regeneration on tooth #6 and 7 (D4266) provided on April 7, 2022. 
 
You asked the Plan to pay for grafts and tissue regeneration. You say that you disagree with the denial of dental 
services The Plan denied your request. The Plan says that a bone replacement graft (D7953) and guided tissue 
regeneration (D4266) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft on tooth #6 and 7 (D7953) and guided tissue regeneration on tooth #6 and 7 (D4266) 
provided on April 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (C9097). 
 
You asked the Plan to pre-approve Vabysmo. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Vabysmo. Our reviewer says that 
Vabysmo is not reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Bevacizumab before they will approve the requested drug. In this case, you have not tried and failed the 
required drug. Our reviewer also found that there is no documentation provided indicating that the Plans 
required drug would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (C9097).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethason tablets. 
 
You asked the Plan to pre-approve Dexamethason tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Dexamethason tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethason tablets.  
 
Benefits for Dexamethason tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on April 20, 2022. 
 
You asked the Plan to pay for x-rays. You say that you disagree with the denial of dental services. 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 Plan's 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 April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for additional periapical x-rays (D0230) provided on 
April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022 billed with 
21 individual codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid. The Plan denied your 
request. The Plan says some codes were approved; however, the rest were denied for various reasons. 
 
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 
January 31, 2022 billed with 21 individual codes.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 60 one-way trips 
per year and additional trips will not be approved. 
 
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 60 one-way transportation 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 additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from March 23, 
2022, to March 24, 2022, related to a surgical procedure coded as 37182. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you feel that this should be allowed 
to be paid as outpatient as the enrollee was low-risk and the services rendered were appropriate. The Plan 
denied your request. The Plan says this must be resubmitted as inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that codes that have an OPPS indicator of "C" are 
inpatient-only services that can only be paid when billed on an inpatient claim. 
 
We looked at the file and Medicare rules. Code 37182 has an OPPS indicator of C and is inpatient-only. Based 
on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not 
been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided 
from March 23, 2022, to March 24, 2022, related to a surgical procedure coded as 37182.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and trigger point injection (99203 and 20553) 
provided on February 17, 2022. 
 
You asked the Plan to pay for codes 99203 and 20553. 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. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for codes 99203 and 20553 until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit and trigger point injection (99203 and 20553) 
provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the bone replacement graft - retained natural tooth (D4263). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that without the bone replacement graft 
your dental work cannot be completed. The Plan denied your request. The Plan says that the service being 
requested is not a covered benefit under your dental plan.  
 
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. Specifically, the Plan did not provide the English version of the Evidence of 
Coverage (EOC) for the contract, only the Spanish version was submitted. This means that we 
are unable to verify if the bone replacement graft is in fact not a covered service. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pre-approve bone replacement graft - retained 
natural tooth (D4263).  
 
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.