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

 
We decided that the Plan does not have to pre-approve Medtronic Infuse Bone Graft Allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Metronic Infuse Allograft in the setting of 
anterior cervical spine fusion surgery have not been demonstrated in the 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 services. 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 an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested Medtronic Infuse Allograft in the setting of anterior cervical spine fusion, 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse Bone Graft Allograft (CPT code 20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - porcelain fused to high noble metal 
(D6240), the retainer crown - porcelain fused to high noble metal (D6750), and endodontic therapy, premolar 
tooth (D3320). 
 
You asked the Plan to pre-approve the dental services as requested. You say that you believe these dental 
services should be covered by the supplemental benefit. The Plan denied your request. The Plan says these 
dental services are not among those covered under the Plan'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 the 
pontic - porcelain fused to high noble metal (D6240), the retainer crown - porcelain fused to high noble metal 
(D6750), and endodontic therapy, premolar tooth (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional amount for extractions and alveoloplasty 
in conjunction with extractions.  
You asked the Plan to pre-approve an additional amount for the dental services. You say that you need to have 
an extraction completed before scheduling a heart procedure. The Plan denied your request. The Plan says you 
are responsible for any amount above the dental coverage limit. 
 
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 annual allowance of $800 has been 
reached with the approval by the Plan. Any amount above the dental coverage limit is your responsibility. 
Additionally, 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 an 
additional amount for extractions and alveoloplasty in conjunction with extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on November 8, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (99100) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2502) provided on March 3, 2021. 
 
You asked the Plan to pay for the contact lenses. You say that you were led to believe you had vision benefits 
and you should be reimbursed for these services. The Plan denied your request. The Plan says they have agreed 
to reprocess some of these claims; however, you received eyeglasses on March 8, 2021. You are covered for 
one pair of eyeglasses or contact lenses per calendar year. The contact lenses exceed the frequency limitations 
of your benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to 1 unit per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan has paid for eyewear for you in 2021 
on a separate visit. Based on this information, we decided that the Plan's rules for coverage of the contact lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses (V2502) 
provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6061), and a custom 
fabricated abutment (D6057) to be provided by a participating provider. 
 
You asked the Plan to pre-approve an abutment supported crown and a custom fabricated abutment. You say 
that you would like Plan to pay for this. The Plan denied your request. The Plan says the requested dental 
services 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. 
 
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 an abutment supported crown (D6061), and a custom fabricated abutment (D6057) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network transplant consultation.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested
physician. The Plan denied your request. The Plan says you were given the names of providers in network who
can provide this treatment. Maximus overturned the Plans denial. The Plan requested a reopen and stated it was
confirmed with you that there were network providers available, but you refused to use them.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers
only in cases involving emergencies, out of area urgent care and care that cannot be provided by network
providers. The provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. Therefore, we decided that the Plan does not have
to pre-approve out of network transplant consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including 
all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), and harness 
for upgrade to expandable controller (CPT code E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
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 DME have not been met. The requested special power 
wheelchair (Group 3 power wheelchair) and some of the requested accessories are medically necessary for you 
per Medicare rules. They will be covered. Some items are however still denied. The upgraded electronics 
(expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They 
are necessary when there is a medical need to control power options though the joystick. The notes do not show 
a medical need to control the power options through the joystick. The power options can be controlled using 
their own switches. These switches can be made any size without asking for a separate request. They can be 
made from any material without asking for a separate request. All of this can be done without the need to use 
the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve 
electronic connection between wheelchair controller and two or more power seating system motors, including 
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware 
(CPT code E2311), expandable controller, including all related electronics and mounting hardware, upgrade 
provided at initial issue (CPT code E2377), and harness for upgrade to expandable controller (CPT code E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met. The 
preoperative clearance and comorbid conditions suggest that the procedure could initially be performed on an 
ambulatory/observation basis. There is no documentation provided to support the expectation the enrollee will 
require a greater than two midnight stay. The inpatient level of care is not reasonable or medically necessary. 
Our physician reviewer found the enrollee has been approved for elective shoulder surgery.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, 
spine, lumbosacral (72100) radiologic examination, spine (72020) provided January 17, 2022. 
 
You asked the Plan to pay for the chiropractic service. You say that your chiropractor is licensed and needed to 
do x-rays to see how to treat you for walking. The Plan denied your request. The Plan says this service is not 
covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, spine, lumbosacral 
(72100) radiologic examination, spine (72020) provided January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves rendered on November 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded. 
 
We looked at the file and Medicare rules. Billed procedure code A4930 (sterile gloves, per pair) has a status 
indicator of X and is statutorily excluded. Therefore, we decided that the Plan does not have to pay for the 
sterile gloves rendered on November 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health visits. 
You asked the Plan to pre-approve the 4 additional home health visits. You say that the requested home health 
services are medically necessary for treatment of her weakness. The Plan denied your request. The Plan says 
they have approved 3 visits to intensely focus on finalizing the home exercise program. The Plan says that the 
remaining 4 home health visits requested are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 4 additional home health visits. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation that skilled therapy services are required to effectively provide treatment, care, and/or services 
in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain 
the enrollee's level of function and/or prevent deterioration. Based on the available records the enrollee appears 
to have improved with therapy to the point of being independent with transfers and supervision level with 
ambulation. After nineteen therapy treatments (plus three additional visits) records do not support that the 
complexity of the enrollee's conditions are such that the skills of a professional therapist are required to achieve 
further improvement in the enrollee's symptoms or functional status. 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 the 4 additional home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2391 x 2) provided on November 22, 2021, by 
the out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that you found this dental office in the provider 
directory. You say that The Plan denied your request. The Plan says fillings received out of network are not 
covered. 
 
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 and fillings are listed as covered, 
fillings received out of network are not among those covered under this benefit.  Therefore, we decided 
that the Plan does not have to pay for the fillings (D2391 x 2) provided on November 22, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided December 17, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you needed the services to address dental 
pain. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 limited oral 
exams once per plan year. 
 
We looked at the file and Plan rules. The Plan provided documentation showing that a limited oral exam was 
previously covered on December 6, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation - problem focused (D0140) provided December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for the approved total shoulder 
arthroplasty. 
 
You asked the Plan to pre-approve inpatient admission. You say that the requested inpatient admission for the 
approved total shoulder arthroplasty is medically necessary. The Plan denied your request. The Plan says the 
requested inpatient admission for the approved total shoulder arthroplasty 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 inpatient admission. Our reviewer says 
that the requested inpatient admission for the approved total shoulder arthroplasty is not medically necessary. 
Our physician reviewer found detailed documentation is not evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay.  There is no documentation provided to expect that the enrollee will require a greater than 2-
midnight stay.  There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested inpatient admission for 
the approved total 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission for the approved total shoulder arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutment (D6191 x 2), semi-precision 
attachment (D6192), and endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the 
requested services are not listed as covered. 
 
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 semi-precision 
abutments, semi-precision attachment, and endosteal implant are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve semi-precision abutment (D6191 x 2), semi-
precision attachment (D6192), and endosteal implant (D6010).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).

You asked the Plan to pre-approve additional routine transportation trips. You say that you receive dialysis indefinitely, three times a week. You also say you require wheelchair transportation and physical assistance for transfers for which your caregivers are unable to provide. You are requesting authorization for additional trips to ensure continuity of care and safety. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.

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 Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. The records show that you have used fifty-three (53) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).