Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site 
(D4266) Tooth #23, 24, 25, 26, and autogenous connective tissue graft procedure (including donor and 
recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273) Tooth #23, 24, 25, 
and 26 provided on November 1, 2022. 
 
You asked the Plan to pay for dental services. You say that the services were processed under the wrong 
insurance. The Plan denied your request. The Plan says the enrollee was covered for preventative dental 
services such as routine dental services and did not become eligible for the optional supplemental coverage 
until 1/1/2023. 
  Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for guided tissue regeneration - 
resorbable barrier, per site (D4266) Tooth #23, 24, 25, 26, and autogenous connective tissue graft procedure 
(including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273) 
Tooth #23, 24, 25, and 26 provided on November 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Advair Diskus. 
 
You asked the Plan to pre-approve Advair Diskus. You say that the enrollee needs this medication. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Advair Diskus.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support medical necessity for admission to an IRF. The 
enrollee has no medical complexity currently or acute rehabilitation nursing needs for an IRF admission. Progressing well functionally. The enrollee would benefit from physical therapy (PT) and occupational therapy 
(OT) and the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such 
as continued in home with services or continue in a skilled nursing facility (SNF) with intermittent therapies. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this service is considered experimental and investigational as it is not 
identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-
reviewed medical literature published in the English language. 
 
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 the Vertiflex spacer is experimental. More research is needed. 
 
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 the Vertiflex superion device placement surgery (22869 and 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF 
setting have not been met. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement; however, the documentation doesnt support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility. The enrollee can receive further services 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 IRF admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for a second opinion to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit for a second opinion to be provided by an out-of-network (OON) provider.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) 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 ACH 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 (LTC) 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation treatment delivery 
(IMRT), includes guidance and tracking, when performed; complex (77386x20) and guidance for localization 
of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed 
(77387x20). 
 
You asked the Plan to pre-approve IMRT. You say that the radiation is targeted for the enrollee's liver. The 
Plan denied your request. The Plan says the enrollee has a history of lymphoma (liver primary). This would be 
easily achievable with 3DCRT. The treatment exceeds the enrollee's medical need, and it 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found conventional 3D conformal radiation may achieve acceptable normal tissue dose exposure and 
target coverage. Generally, an insufficient conventional 3D conformal plan warrants consideration for IMRT. 
The case file does not show that, in this particular enrollee, that IMRT versus 3D radiation results in clinically 
significant lowering of dose to the normal tissues (specifically lung). This appears to be a clinically significant 
reduction. For this enrollee, there is no plan comparison and there is no justification for the need of IMRT over 
3D conformal radiation. The ASTRO model policy requires justification of the need for IMRT, which is 
generally the case when IMRT is considered for cases for which it is not standard. Given the lack of 
justification of need, the decision is unfavorable as routine use of IMRT would not be furnished in accordance 
with accepted standards of care and the LCD criteria are not 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when 
performed; complex (77386x20) and guidance for localization of target volume for delivery of radiation 
treatment, includes intrafraction tracking, when performed (77387x20).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - four 
or more teeth or tooth spaces (D7320). 
 
You asked the Plan to pre-approve alveoloplasty not in conjunction with extractions. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested service is not a covered 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 
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces (D7320).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units of code 87798 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the billed services Our reviewer says that the 
records provided do not support the number of units billed. Our physician reviewer found that the laboratory 
report does not support 13 units of code 87798 were provided in this case. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for 13 units of code 87798 billed for date of service October 25, 2022.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 clinical documentation does not specify any complex functional impairments or 
active medical comorbidities; thus, the complexity of your documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. IRF criteria not 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If there is chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 
77386, G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the purpose of this request is to ask that the denial of 
twelve treatment doses of IMRT for treatment of unspecified B-cell lymphoma, lymph nodes of inguinal region 
and lower limb, be overturned. The Plan denied your request. The Plan says the enrollee has a history of groin 
lymphoma. IG-IMRT would not be standard for this anatomic site/tissue diagnosis/relatively low dose. The 
request does not meet the Medicare or health plan coverage criteria. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the international lymphoma radiation oncology group's (ILROG) states: In some situations, 
conventional anteroposterior posteroanterior techniques may be preferred, because the smallest volume of 
normal tissue will be irradiated, albeit to the full prescribed dose. In other situations, more conformal 
techniques such as IMRT, arc therapy, or tomotherapy may offer significantly better sparing of critical normal 
structures, usually at the price of a larger total volume of normal tissue irradiated, albeit to a lower dose. 
However, in some clinical scenarios, IMRT, inspiration breath-hold techniques, and image-guided radiation 
therapy (IGRT) may offer significant and clinically relevant advantages and should be used. The discussion 
focuses on IMRT for mediastinal radiotherapy. For this enrollee, planned to receive 24 Gy, there is no plausible 
rationale for the need of IMRT over 3D conformal radiation. Simply showing that IMRT reduces exposures to 
organs at risk does not establish necessity, when then the plan comparisons do not show an unacceptable non-
IMRT plan or show a plausible clinically meaningful benefit of IMRT. While there is a plan comparison there 
is no dosimetric justification for the need of IMRT over 3D conformal radiation. The ASTRO model policy 
requires justification of the need for IMRT, which is generally the case when IMRT is considered for cases for 
which it is not standard. Given the lack of justification of need, the decision is unfavorable as routine use of 
IMRT would not be furnished in accordance with accepted standards of care and the LCD criteria are not 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 77386, G6002, G6015).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the land transport was medically required 
by the attending physicians as returning home by air as planned was not allowed for medical reasons. The Plan 
denied your request. The Plan says charges for non-emergency transport are excluded from coverage under 
your plan. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says 
that transportation via ambulance was not medically necessary. Our physician reviewer found while you may 
have not been able to fly, there is no documentation to show that the required ambulance, rather than any other 
means of ground transport (stretcher van, wheelchair van, private car, bus taxi) was 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on July 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS panels are covered for the indications 
established in the applicable NCD. 
 
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 genetic testing. Our reviewer says that 
the requested genetic testing is medically reasonable and necessary. Our physician reviewer found that the 
NCCN Guidelines, Version 2.2022 Systemic Mastocytosis, recommends testing for multiple molecular markers 
and multigene NGS panels are recommended. This testing is medically reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing.  
 
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.