Persius/hicric huggingface dataset:
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 needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns - porcelain fused to high noble metal 
(D6750), pontics - porcelain fused to high noble metal (D6240), bone replacement graft  retained natural tooth 
 first site in quadrant (D4263), and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided October 20, 2020. 
 
You asked the Plan to pay for the retainer crowns, pontics, bone replacement graft and tooth extraction. You 
say that these services should be covered. The Plan denied your request. The Plan says these services are not 
covered under your 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 the 
retainer crowns - porcelain fused to high noble metal (D6750), pontics - porcelain fused to high noble metal 
(D6240), bone replacement graft  retained natural tooth  first site in quadrant (D4263), and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) provided October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services to be provided by an oral surgeon. You say that your tooth 
has a hole and it down to the nerve causing pain. The Plan denied your request. The Plan says the requested 
services must be provided by a general dentist. 
 
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 dental services to be provided by an oral 
surgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybrevant infusions. 
 
You asked the Plan to pre-approve Rybrevant infusions. You say that you would like Amivantamab to be 
approved for coverage. The Plan denied your request. The Plan says this therapy is not medically appropriate 
for the enrollee's treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rybrevant infusions. Our reviewer says 
that Rybrevant infusions are not medically reasonable and necessary. Our physician reviewer found the 
literature, compendia and Food and Drug Administration (FDA) label do not support the use of the requested 
drug for the enrollee's diagnosis. Our reviewer also found that the drug is only approved for an exon 20 
insertion mutation. The enrollee has an exon 14 mutation, which does not qualify as an indication for this drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rybrevant infusions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Rybrevant infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on May 
25, 2021. 
 
You asked the Plan to pay for dental services. You say that the Plan should pay for this. The Plan denied your 
request. The Plan says the maximum annual allowance amount 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. The Plan covers covered 
dental services up to a $1,000 dental maximum allowance amount.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the dental annual allowance 
amount has already been met and exhausted. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met.  
 
Therefore, we decided that the Plan does not have to pay for dental services provided by a participating 
provider on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition (D8090), pre-orthodontic treatment examination (D8660), and orthodontic retention (D8680). 
 
You asked the Plan to pre-approve a comprehensive orthodontic treatment of the adult dentition, pre-
orthodontic treatment examination, and orthodontic retention. You say that you would like the Plan to provide 
the necessary benefits because these measures are therapeutic and medically necessary, not cosmetic. The Plan 
denied your request. The Plan says these services are not covered under the enrollee's benefit package. 
 
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 a 
comprehensive orthodontic treatment of the adult dentition (D8090), pre-orthodontic treatment examination 
(D8660), and orthodontic retention (D8680).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgical techniques for a spinal surgery. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT code 69990 should not be reported with other procedures even if an operating microscope is 
used. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the requested service 
should not be requested or reported separately. Our reviewer found that CPT code 69990 should not be billed 
with laminectomy and fusion codes as it is included in the payment for the laminectomy. It cannot be 
unbundled. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for microsurgical techniques for a spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four alveoloplasties in conjunction with extractions 
(D7311 x4). 
 
You asked the Plan to pre-approve the alveoloplasties. You say that it has been deemed medically necessary 
and approved by the Plan for the removal of all of your teeth in order for you to be fitted for dentures. You also 
say that the alveoloplasties are strongly recommended because the dentist does not believe the dentures will for 
a tight seal and will likely loosen while you are eating. The Plan denied your request. The Plan says this service 
is not a covered benefit under your plan. 
 
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 four alveoloplasties in conjunction with 
extractions (D7311 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865), 
modification of removable prosthesis following implant surgery (D5875), and three prefabricated abutments 
(D6056 x3). 
 
You asked the Plan to pre-approve the complete mandibular overdenture, modification of removable prosthesis, 
and prefabricated abutments. You say that it is medically necessary that you have an overdenture for your 
bottom denture. You also say that you are not asking for anything over the $3,000 dental allowance that you 
have available for the 2022 plan year. The Plan denied your request. The Plan says these services are not 
covered under your benefit package. 
 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 a 
complete mandibular overdenture (D5865), modification of removable prosthesis following implant surgery 
(D5875), and three prefabricated abutments (D6056 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on November 
15, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, the medical records do not 
indicate that there was an independent trained observer present while the services were rendered. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on 
November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate conscious sedation (99152). 
 
You asked the Plan to pre-approve the sedation services. You say that your injection was approved but not the 
sedation that goes along with it. You cannot go through an injection without the sedation The Plan denied your 
request. The Plan says the use of moderate or deep sedation, general anesthesia, and monitored anesthesia care is 
usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and 
necessary. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pre-
approve moderate conscious sedation (99152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554). 
 
You asked the Plan to pre-approve the CGM device. You say that the enrollee was prescribed insulin which 
causes blood sugar to drop. The enrollee does not feel when he has a blood sugar drop and he can go into a 
diabetic coma which may cause death. The Plan denied your request. The Plan says the enrollee is on insulin 
once a day and does not require changes in insulin dosage based on blood sugar and therefor, does not meet the 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary.  
 
 Our physician reviewer found that based on the medical records provided, there is no documentation that this 
patient has neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to 
chronic obstructive pulmonary disease; her diagnoses are morbid obesity and obesity hypoventilation syndrome 
with chronic respiratory failure. The records do not show trial and failure of a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards, swingaway arm rests, calf pads, and a free 
wheel with hardware for a manual wheelchair. 
 
You asked the Plan to pre-approve 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 for equipment to be covered, it must primarily serve a 
medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use 
inside the home. The rules say that DME that serves the same purpose as equipment already available to an 
enrollee is not covered. 
 
The requested side guards do not serve a purpose that is primarily medical in nature. The requested free wheel 
and hardware are for use outside of the home and Medicare does not cover equipment for this use. The 
requested swingaway arm rests and calf pads are not covered because they are already included in the approved 
manual wheelchair and would be duplicate equipment. Therefore, we decided that the Plan does not have to 
pre-approve side guards, swingaway arm rests, calf pads, and a free wheel with hardware for a manual 
wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venipuncture (36000), additional supplies and material 
over and above those usually included (99070), and the surgical supplies (A4649) provided on May 14, 2021.  
You asked the Plan to pay for the items/services as billed. You say that this should be paid. The Plan denied 
your request. The Plan says approval for payment of the services rendered was issued. However, some billed 
codes are 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. 
 
We find that CPT codes 36000 and 99070 have status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 36000 and 99070 are not separately payable. Code A4649 has a status indicator of "P". 
This means that separate payment is not made if physician services are also provided. As such services were 
also provided, no separate payment can be made for A4649. Based on this information, we decided that 
Medicare rules for coverage of the items/services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the venipuncture (36000), additional supplies and material over and above those 
usually included (99070), and the surgical supplies (A4649) provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the claim. The 
Plan denied your request. The Plan says the panel does not meet coverage criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that a hereditary cardiovascular screening panel was provided. The records do not show that the 
testing was ordered by the enrollees treating physician for a specific diagnosis or treatment strategy. The test 
at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with high gold content crown for tooth 
#10. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this treatment may not give a successful and long-term result. 
 
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 the services 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
provided for review was not adequate to determine if the criteria for coverage have been met. The radiographs 
were diagnostically inadequate and there was no narrative indicating the reason for the need for the service. 
 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a white glass with high gold content crown for tooth #10.