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

 
We decided that the Plan does not have to pre-approve decitabine (J0894). 
 
You asked the Plan to pre-approve decitabine. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, azacitidine. 
 
 
 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 decitabine. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. 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 decitabine have not been met. Therefore, we decided that the Plan does not have 
to pre-approve decitabine (J0894).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Posterior Tibial Nerve Stimulation.
You asked the Plan to pre-approve the Posterior Tibial Nerve Stimulation. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that coverage for initial therapy must document failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug therapy despite best attempts at management of the most common side effects of such therapy, such as dry mouth and constipation. 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 Posterior Tibial Nerve Stimulation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not document failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug therapy despite best attempts at management of the most common side effects of such therapy, such as dry mouth and constipation. 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 Posterior Tibial Nerve Stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve the Posterior Tibial Nerve Stimulation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular panel (81410, 81479, 81408, 81407, 
81311 and 81401) provided on May 23, 2020. 
 
You asked the Plan to pay for the cardiovascular panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this testing was not initiated by the 
enrollee's treating physician. 
 
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 test at issue in this appeal, the cardiovascular panel, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Additionally, the documentation indicates that this testing 
was not ordered by the enrollee's physician or that the results of this testing will impact the course of the 
enrollee's treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular panel 
(81410, 81479, 81408, 81407, 81311 and 81401) provided on May 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac computed tomography (CT) scan with calcium 
scoring. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically and doesn't meet the plan's criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
Medicare does not consider this type of imaging, with calcium scoring, to be medically necessary. Based on 
this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve cardiac computed tomography (CT) scan with calcium 
scoring.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a privacy flap (K0108). 
 
You asked the Plan to pre-approve a privacy flap. You say that the requested equipment is medically necessary. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit at the time the equipment was requested. Therefore, we decided that the Plan does not have to pre-approve a privacy flap (K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 29, 2021, 
through October 7, 2021. 
 
You asked the Plan to pay for the home health services. You say that the denial is incorrect because no place of 
service is on home health claims. The Plan denied your request. The Plan says the required Q-code is not 
reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must report where home 
health services were provided using one of three Q-codes. The location where services were provided must 
always be reported along with the first visit reported on the claim. 
 
We looked at the file and Medicare rules. We find that the Q-code was not billed on the same date of service as 
the first visit reported on the claim. The first visit was a physical therapy visit on September 29, 2021.  The code Q5001 was billed on date of service October 7, 2021. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from September 29, 2021, through October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) spinal canal and 
contents (72141). 
 
You asked the Plan to pay for the MRI. You say that the medical records provided support the necessity of the 
services in dispute. The Plan denied your request. The Plan says the claim denied due to being unbundled 
service. 
 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 72141 
is a column II code to column I code 72156. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) spinal canal and contents 
(72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven abutment supported cast metal crowns (D6063 x7). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. The Plan denied your request. 
The Plan says this service is not covered under your benefit 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 
seven abutment supported cast metal crowns (D6063 x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network dental services (D7140, D0140, D0220) 
provided September 28, 2021 to October 7, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that these services should be 
covered. The Plan denied your request. The Plan says the services were covered with the appropriate cost-
sharing applied per the plan contract. 
 
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 plan contract states that the plan will pay 100% of the average in-network rate for out-of-network dental services. If the out-of-network provider charges more than this amount, the enrollee is responsible for the difference. In this case, the amount charged exceeds the in-network average for your area. The enrollee is responsible for the difference in this case. Therefore, we decided that the Plan does not have to pay for out-of-network dental services (D7140, D0140, D0220) provided September 28, 2021 to October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4). 
 
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit plan. 
 
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 four 
gingival irrigations (D4921 x4).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the head. 
 
You asked the Plan to pre-approve MRI services. You say that this imaging service is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met as an examination by a 
doctor has not shown signs of abnormal brain function as required by Medicare rules before an MRI will be 
approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says that 
the requested imaging service is not medically reasonable and necessary. Our physician reviewer found the 
patient is a 58-year-old female with chronic migraine without aura. An MRI of the head was requested. At the 
time of this request, the patient was also started on Emgality for the first time and there was no report of how 
effective this treatment has been thus far. The patient reported her headaches having photophobia, 
phonophobia, nausea, vomiting, and neck pain and provoked by neck pain. The documentation did not clearly 
describe signs or symptoms suggestive of a red flag diagnosis as she had more classic tension and migraine-
tight headache symptoms. There was no plan for a procedure or failure of treatments for her condition to justify 
an MRI at this time. Therefore, the MRI head will be considered not medically necessary at this time based on 
the provided documentation. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) scan of the head.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 mini implants (D6013) and an overdenture (D5863). 
 
You asked the Plan to pre-approve the dental services. You say that a mandibular overdenture will be necessary 
in order to properly restore the lower arch after implant placement. 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 and mini implants are listed as covered, 
the frequency limit of 2 per calendar year has been reached. The record shows that the Plan initially approved 2 
of the 4 total mini implants that were requested. Additionally, the requested overdenture is not among those 
covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve 2 mini implants (D6013) and an overdenture 
(D5863).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) provided January 23, 2020. 
 
You asked the Plan to pay for the surgical procedure. You say that you are requesting reimbursement for the 
out-of-pocket cost of laser used during cataract surgery. The Plan denied your request. The Plan says this 
service is not covered as the claim was received past 6 months from the date of service and no supporting 
documentation was submitted from the enrollee or the provider. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the extracapsular cataract removal with 
insertion of intraocular lens prosthesis (66984) provided January 23, 2020. have been met. the claim was 
received past 6 months from the date of service and despite multiple attempts the Plan did not receive any 
supporting documentation from the enrollee or the provider. Therefore, we decided that the Plan does not have 
to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) provided 
January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cleaning, oral exam, and x-ray to be provided by an 
out of network dentist.
 
You asked the Plan to pre-approve out of network dental services. You say that you have been seeing this 
dentist for over 35 years. You also say that you would hate to start over now with someone new. The Plan 
denied your request. The Plan says there are in network dentists available to provide the services. 
 
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, dental services performed by an out of 
network dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a cleaning, oral exam, and x-ray to be provided by an out of network dentist
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2391) for tooth # 28 provided on November 16, 
2021, by an out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that you were sent a list of covered dentists in your 
area. You say that you picked this office because it was near your home. You also say that the office advised 
they accepted your insurance. The Plan denied your request. The Plan says the provider in this case is out of 
network. The Plan also says that dental services obtained 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services obtained out of network 
are not among those covered under this benefit. The record shows that the provider in this case is not listed as 
an in network provider. Therefore, we decided that the Plan does not have to pay for the filling (D2391) for 
tooth # 28 provided on November 16, 2021, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth #'s 2, 3, 4, 5, and 6, pontics (D6245) for tooth #'s 3 and 5, and retainer crowns (D6740) for 
tooth #'s 2, 4, and 6. 
 
You asked the Plan to pre-approve the core buildups, pontics, and retainer crowns. You say that you are on a 
fixed income, need dental care, and have dental insurance. The Plan denied your request. The Plan says these 
services 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 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 core 
buildups, including any pins when required (D2950) for tooth #'s 2, 3, 4, 5, and 6, pontics (D6245) for tooth #'s 
3 and 5, and retainer crowns (D6740) for tooth #'s 2, 4, and 6.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your dialysis appointments. The Plan denied your request. The Plan says that this benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve the dental service. You say that it does not make sense that D0150 and 
D4355 are separated by 1/12 months. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 the service is listed as covered, the 
record shows that the enrollee received a comprehensive oral evaluation on March 3, 2022, less than 12 months 
ago. Therefore, we decided that the Plan does not have to pre-approve full mouth debridement to enable a 
comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) for tooth #11. 
 
You asked the Plan to pre-approve the core buildup. You say that you would like the continuation of the crown 
for tooth #11 to be approved for coverage. The Plan denied your request. The Plan says this service is not 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950) for tooth #11.
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 appears to be more stable and requires additional short-term acute 
care to further stabilize that can be safely completed at the current facility until they are more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Transfer to a lower level of care may be considered when treatment has completed at the current 
facility. 
 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.