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

 
We decided that the Plan has to pre-approve sacral nerve stimulator lead and pulse generator replacement. 
 
You asked the Plan to pre-approve sacral nerve stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 sacral nerve stimulator. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found testing has shown that the enrollee's current implanted device is not functioning and 
requires replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral nerve stimulator have been met. Therefore, we decided that the Plan has 
to pre-approve sacral nerve stimulator lead and pulse generator replacement.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #3. 
 
You asked the Plan to pre-approve a crown. You say that the x-ray shows the decay present at the mesio-buccal 
cervical junction that cannot be fixed by a simple filling. You also say that a crown is required to restore this 
tooth. The Plan denied your request. The Plan says the crown is not medically necessary. 
 
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 covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
requested crown is not supported by the supplied documentation. Our physician reviewer found the tooth in 
question does not have sufficient structural damage as to require a crown under the Plan. Usually, 50% or more 
of the structure being damaged or missing allows for consideration of a full coverage crown. Our reviewer also 
found that in this instance, there is less than 33% damage to the structure, and it appears the tooth would be 
restorable with a direct filling material and not in need for a crown.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #3.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 
19, 2022 to April 10, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says clinically the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) care provided from March 19, 2022 to April 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myrisk laboratory procedure (81479). 
 
You asked the Plan to pre-approve laboratory services. You say that additional medical records were submitted 
to show medical necessity. The Plan denied your request. The Plan says genetic tests must be cleared or 
approved by the FDA and have been registered or evaluated by the Medicare (MoIDX) molecular diagnostic 
test program to determine the validity or usefulness of the results for patient care. The Myrsik laboratory 
procedure has not been approved by the FDA. Therefore, this procedure is not covered by the plan. 
 
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. The records show that the requested procedure has not been approved 
by the FDA and therefore, is not covered by the Plan. Based on this information, we decided that Medicare 
rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Myrisk laboratory procedure (81479).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby service (CPT code 99360) provided on May 18, 
2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
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 service have not been met. The rules say that standby services 
are not payable to physicians. Physicians may not bill Medicare or beneficiaries for standby services. Payment 
for standby services is included in the Part A payment to the facility. Such services are a part of hospital costs 
to provide quality of care. If hospitals pay physicians for standby services, such services are part of hospital costs to provide quality care. Therefore, we decided that the Plan does not have to pay for the standby service 
(CPT code 99360) provided on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38525 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 38525. The Plan denied your request. The Plan says payment for 
code 38525 is bundled into payment for code 38745. 
 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 38525 
is a column II code to column I code 38745. 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 38525 billed for date of 
service March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laminectomy procedures (63047, 63052) provided on 
January 5, 2022. 
 
You asked the Plan to pay for laminectomy procedures. You say that this is supported in the records. The Plan 
denied your request. The Plan says 63047 is not documented and 63052 is part of the primary procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 63047 is laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; lumbar. The definition of 63052 is laminectomy, 
facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or 
nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single 
vertebral segment (List separately in addition to code for 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 laminectomy procedures. Our reviewer says that these codes 
are not supported. Our reviewer found the operative report does not include sufficient documentation to 
confirm laminectomy, facetectomy and foraminotomy was performed, so 63047 is not supported. The operative 
report also does not include sufficient documentation to confirm decompression beyond preparation of the 
interspaces for fusion was performed, so the use of modifier -59 on 63052 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laminectomy procedures have not been met. Therefore, we decided that the Plan 
does not have to pay for laminectomy procedures (63047, 63052) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15. 
 
You asked the Plan to pre-approve a crown. The Plan denied your request. The Plan says the treatment is 
denied due to subcrestal caries. 
 
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 covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
provided documentation does not support the need for a crown at this time. Our physician reviewer found 
crowns would not be acceptable in situations where it could not be properly placed in proximity to the 
supporting bone. Our reviewer found in this case the decay is too close to the bone level to allow for proper 
placement of the margin of the crown. Our physician reviewer also found that currently there is no necessity for 
a replacement crown given the clinical situation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on March 24, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that you contacted the Plan and were assured you have 
been covered for five years with no break in service. The Plan denied your request. The Plan says you were not 
eligible when this service was performed. 
 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 service is only covered 
when you use your benefit card to pay for it. The record does not show that you used your benefit card to pay 
for this service. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided 
on March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP Allograft procedure. 
 
You asked the Plan to pre-approve Medtronic Infuse BMP Allograft. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the clinical value and effectiveness of this 
procedure have not been demonstrated. 
 
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 Medtronic Infuse BMP Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published large-scale, long-term, peer-reviewed literature 
that shows this request to be safe and/or effective for the noted pathology. Further studies are needed to show 
the efficacy of the requested allograft for use in the cervical spine. There is no compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic Infuse BMP Allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medtronic Infuse BMP Allograft procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil Citrate. 
 
You asked the Plan to pre-approve Sildenafil Citrate. You say that the enrollee has been using generic 
Sildenafil since January 2020, with an excellent response. You also say that this medication has been very 
effective for the enrollee and is medically necessary. The Plan denied your request. The Plan says Sildenafil 
Citrate is not of a type and/or used for a condition that is covered under the medical benefit for outpatient 
prescription drugs. 
 
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 Sildenafil Citrate.  
 
Benefits for Sildenafil Citrate 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 6, 2022, to 
February 24, 2022. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the provider 
did not bill as required by Medicare coding regulations. The provider submitted NOA with date of service 
February 06, 2022, but in the final claim image the admit date is September 14, 2020, which does not match, 
required valid NOA.  
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA must always 
match the from date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided from February 6, 2022, to February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that Medicare has paid for this service in the 
past. The Plan denied your request. The Plan says the requested service 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is considered experimental as more research is 
needed. Therefore, the reviewer found that the requested procedure 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 Intracept procedure have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81529) billed for date of service June 22, 
2022. 
 You asked the Plan to pay for laboratory services. You say that this test is classified as an advanced diagnostic 
laboratory test which is covered by Medicare. The Plan denied your request. The Plan says this claim was 
billed with an incorrect date of service. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service. There are some exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record shows that the sample in this case 
was collected in a non-hospital setting, which means that no exception to the applied rule has been met. The 
record shows that this test was performed on June 13, 2022, and the specimen was collected on June 6, 2022. 
June 6th would be the correct date of service in this case, and it is unclear how the reported date relates to the 
services at issue. Therefore, we decided that the Plan does not have to pay for laboratory testing (81529) billed 
for date of service June 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are functioning at a community level. As a practical matter you do not require a 
skilled nursing stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341) for the upper left quadrant. 
 
You asked the Plan to pre-approve periodontal scaling and root planing for the upper left quadrant (D4341). 
You say that this service is medically necessary. The Plan denied your request. The Plan says there are only 
three teeth noted in this area of the mouth. Dental code D4341 requires 4 or more teeth to be approved. 
 
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. 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 periodontal scaling and root planning 
for the upper left quadrant. Our reviewer says that in order to qualify for scaling under D4341 there must be 
four or more involved teeth in a quadrant.  In this case there are three teeth remaining and charted, which 
would require a different code used for the limited number of teeth.  As there are insufficient involved teeth in 
the upper left quadrant, the requested treatment would not be medically necessary. 
 
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 
periodontal scaling and root planing-four or more teeth per quadrant (D4341) for the upper left quadrant.