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

 
We decided that the Plan does not have to pre-approve Avsola (Q5121). 
 
You asked the Plan to pre-approve Avsola. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Remicade, Inflectra, infliximab, or Simponi Aria. 
 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 Avsola. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has not tried and failed the preferred drugs. The reviewer found that there is no indication that 
the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola (Q5121).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D9223, D9222, D9612, D7286) 
 
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 the services denied correctly as they do 
not fall within 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 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 the 
dental services (D9223, D9222, D9612, D7286)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31237 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 31237. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 31237 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 31237 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 31237 billed for date of service June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy pump. 
 
You asked the Plan to pre-approve the requested services. You say that this is the only way to treat the wounds. 
The Plan denied your request. The Plan says the records do not document any elements of a wound therapy 
program. 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy pumps are only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that you have a right groin skin graft infection. The records do not document evaluation, care, 
and wound measurements by a licensed medical professional, an application of dressings to maintain a moist 
wound environment, debridement of necrotic tissue if present, or an evaluation of and provision for adequate 
nutritional status. The records also do not document the medical necessity for accelerated formation of 
granulation tissue which cannot be achieved by other available topical wound treatments as required. 
Therefore, the request is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a negative pressure wound therapy pump.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (E1399). 
 
You asked the Plan to pre-approve the dental implants. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the request is for dental services and is non-covered under your 
benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental implants 
(E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional resin-based composites (codes D2331, 
D2391 x2, and D2393) provided on June 8, 2022. 
 
You asked the Plan to pay for the additional resin-based composites. You say that you cannot afford to pay this 
bill. The Plan denied your request. The Plan says your benefit for the requested service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service January 26, 2022. Therefore, we 
decided that the Plan does not have to pay for the four additional resin-based composites (codes D2331, D2391 
x2, and D2393) provided on June 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 76705 provided on September 3, 2022. 
 
You asked the Plan to pay for code 76705. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code billed is not separately payable. 
 
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 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 76705 provided on September 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 29, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. The Plan denied your request. The 
Plan says you have exceeded your maximum 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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on February 23, 2022, and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for recementing crowns on tooth #8 and 10 (D2920) provided on 
September 24, 2022. 
 
You asked the Plan to pay for recementing crowns. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says that the requested services are part of another service that 
you have received from the provider. 
 
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 did not provide documentation showing what service was included 
with recementing the crowns or that you received any other services on September 24, 2022. Therefore, we 
decided that the Plan has to pay for recementing crowns on tooth #8 and 10 (D2920) provided on September 
24, 2022.  
 
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 core build up services (D2950) 
 
You asked the Plan to pre-approve the core build up services. 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 they 
do not fall within 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 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 core 
build up services (D2950)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that a repeat injection is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat TFESI. Our reviewer says that 
a repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that you have experienced 50% pain relief for at least three months. Therefore, the reviewer found that 
a repeat TFESI is not medically 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 a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 that based on the limited documentation provided, you do not qualify for SNF 
coverage. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of your 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20526 billed for date of service April 11, 
2022. 
 You asked the Plan to pay for procedure code 20526. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 20526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20526 billed for date of service April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation for an approved 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe arthritis. The 
Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer-reviewed 
literature. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for primary osteoarthritis of the left shoulder. Limited 
published, large-scale, long-term peer-reviewed literature shows computer navigation to be an improvement 
over standard techniques for the noted procedure regarding ultimate outcomes of pain relief and functional 
improvement. Further testing/studies are needed to corroborate computer navigation to be beneficial in this 
clinical scenario. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested computer-assisted surgical 
navigation for approved shoulder arthroplasty, in this case, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computer-assisted surgical navigation for an approved shoulder arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you have never paid for labwork before. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab work. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for lab work provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH 
care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The 
enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is tolerating a daytime tracheotomy collar. It is unclear whether 
complete ventilator liberation is expected. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current acute care 
hospital until such time no acute services are required. The enrollee can then be transferred/discharged to a 
lower level of care for any ongoing long term care needs. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 the enrollee continues to fall and has generalized 
weakness, deficits in safety awareness, and is unable to self-propel a wheelchair. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for admission to inpatient rehabilitation and their needs 
can safely be met at a lower level of care. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
 
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 pre-approve an incisional biopsy of oral tissue-soft (D7286). 
 
You asked the Plan to pre-approve the incisional biopsy of oral tissue-soft (D7286). The Plan denied your 
request. The Plan says this service is not covered under the benefit package. 
 
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 incisional biopsy of oral tissue-soft 
(D7286) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an incisional biopsy of oral tissue-soft (D7286).  The Plan agreed to pre-approve the deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic image 
(D0350), or pay more for the comprehensive oral evaluation (D0150), and vertical bitewings (D0277) provided 
on July 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the 2D oral/facial photographic image, and to pay more for the comprehensive 
oral evaluation, and vertical bitewings. The Plan denied your request. The Plan says the 2D oral/facial 
photographic image is not covered under the Plan. The Plan also says that this claim was paid correctly up to 
the annual maximum allowable for an OON provider. 
 
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 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract also says that you are responsible for the 
difference between the billed amount and allowed amounts for the covered dental services because they were 
rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the two-
dimensional (2D) oral/facial photographic image (D0350), or pay more for the comprehensive oral evaluation 
(D0150), and vertical bitewings (D0277) provided on July 18, 2022, by an out-of-network (OON) provider.