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

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 10, 11, and 12 and retainer 
crowns (D6750) for tooth #'s 9 and 13. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need these services 
because your gums have been bleeding since 2017. The Plan denied your request. The Plan says these services 
do not meet the criteria for medical necessity. 
 
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 the pontics 
and retainer crowns 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 pontics and retainer crowns. Our 
reviewer says that these services do not meet the criteria for coverage. Our physician reviewer found the Plan 
provides for fixed bridges in the very limited circumstances where there is one missing upper anterior tooth, or 
two adjacent missing lower anterior teeth and no other teeth are missing in the dental arch aside from third 
molars. Our reviewer found that tooth #12 is a posterior tooth, and it is noted that #15 is missing as well.  Our 
physician reviewer also found that as the limited parameters for a fixed bridge has not been met as there are 
missing posterior teeth in the arch and there is more than one missing anterior tooth to be replaced, the Plan 
does not provide for the requested bridge under its criteria. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 10, 11, and 12 and retainer crowns (D6750) 
for tooth #'s 9 and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on July 1, 2021.
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections. The Plan denied your request. The Plan says multivitamin injections (compounded Nutria), prolotherapy/acupuncture\, into the nerve and musculoskeletal structures are not a Medicare covered benefit. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered. The Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic / vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema.
The Plan must follow Medicare rules. Medicare rules say that the use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or lymphedema. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87798, 87799, 87482) provided July 9, 2021. 
 
You asked the Plan to pay for the lab testing. You say that the lab services were medically necessary. The Plan 
denied your request. The Plan says PCR urine testing is unproven and 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 pay for the lab testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found based on the medical records provided there is no documentation that the PCR 
urine testing at issue in this case meets Medicare criteria for medically reasonable and necessary. Provided 
records do not document any acute urinary symptoms suggestive of a urinary tract infection and records do not 
clarify why PCR urine testing was required as opposed to a standard urinalysis, culture and sensitivity.  
 
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 lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (87798, 87799, 87482) provided July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lidocaine injection services provided on September 30, 2021. 
 
You asked the Plan to pay for the lidocaine injection services. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate 
modifier was not billed with this claim. 
 
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 J2001 
is a column II code to column I code 20611. 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 lidocaine injection services provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on August 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you disagree with the denial, and it was 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on August 5, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #28. 
 
You asked the Plan to pre-approve the crown. You say that this service is medically necessary. The Plan denied 
your request. The Plan says you do not meet the requirements/conditions for approval because the information 
does not show a large crack or chip on the tooth. 
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 the crown 
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 crown. Our reviewer says that a 
crown for tooth #28 does not meet the criteria for coverage. Our physician reviewer found tooth #28 does not 
exhibit any existing restoration or damage to the structure. Our reviewer found that the clinical notes indicate 
endodontic treatment was performed on tooth #28, however an attached x-ray shows a root canal filling in 
tooth #29 and not tooth #28. Our physician reviewer also found that given the lack of any notable decay or 
damage to the tooth from caries or fracture on tooth #28, there can be no finding of necessity for a crown 
restoration. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) for tooth #30 and core buildup, 
including any pins when required (D2950) for tooth #30 provided on December 8, 2021. 
 
You asked the Plan to pay more for the crown and core buildup. You say that you paid 50% upon receiving the 
service which is what you understood to be your responsibility. You also say that you would like the remaining 
$500 to be reimbursed to the provider. The Plan denied your request. The Plan says this claim paid correctly 
because you met the annual maximum for this crown. 
 
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 contract says that you have a 
maximum $100 annual limit per tooth for crowns. The record shows that you met the annual $100 deductible 
for tooth #30 while processing this claim for the December 8, 2021 date of service. Therefore, we decided that 
the Plan does not have to pay more for the crown (D2740) for tooth #30 and core buildup, including any pins 
when required (D2950) for tooth #30 provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 
17, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you are requesting that your plan 
provide more frequent periodontal care because your dentist recommends you be seen at least four times per 
year. You also say that you would like an exception to be made and this service to be covered. The Plan denied 
your request. The Plan says this service exceeded the Plan's limitation of twice in a benefit period. The Plan 
also says that this claim processed 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, you are limited to a maximum of 2 
routine preventive teeth cleanings per calendar year. The record shows that you received a periodontal 
maintenance (D4910) on May 26, 2021, and August 26, 2021 and your routine teeth cleanings benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
18, 2021, to May 21, 2021. 
 
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 the DRG was updated in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 917 (POISONING AND TOXIC EFFECTS 
OF DRUGS WITH MCC). 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 services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the review indicates that the Secondary diagnosis code assignment of E43 (Unspecified severe 
protein-calorie malnutrition) was reported by the hospital. According to coding guidelines and documentation 
in the medical record this condition did not qualify for reporting. From the information that was received, 
documentation was conflicting regarding a diagnosis of severe protein calorie malnutrition. Even though severe 
protein calorie malnutrition is documented in the discharge summary addendum, supporting medical record 
documentation was conflicting within the record. The provider documented in the emergency room report the 
patient is well developed. The provider documented in the history and physical report negative weight loss and 
muscles are age-appropriate tone. As noted above, although the provider documented severe protein calorie 
malnutrition, reasonable support within the health record must be present for that diagnosis. DRG 918: 
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC is more appropriate in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 18, 2021, to May 21, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the clinical information indicates that your needs may be safely met in a less intensive 
setting. 
 
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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a 
past medical history of stroke, and are living at home receiving treatment for chronic bronchitis. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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 pre-approve an office visit 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 to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits and a neuroplasty provided 
from May 10, 2021, to July 8, 2021. 
 
You asked the Plan to waive the copayment for the office visits and neuroplasty. You say that the services 
should be covered as they were ineffective. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers and a $50 copayment for Physician/Practitioner services, including doctors office visits  
You have been asked to pay a $150 copayment for 3 specialist office visits and a $325 copayment for a 
neuroplasty. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for office visits and a neuroplasty provided 
from May 10, 2021, to July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one-
way (rotary wing) A0431) and rotary wing air mileage, per statute mile (A0436) provided June 10, 2021. 
 You asked the Plan to pay for the air transport. You say that based on the clinical information documented 
during transport, you believe that this transport meets medical necessity guidelines and is therefore appealing 
the decision. The Plan denied your request. The Plan says the records do not support that the services provided 
was medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air transport. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is documentation that the enrollee suffered from an 
injury that contraindicated transportation by any means other than ambulance and there is documentation that 
the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. 
There is no documentation that the enrollee's condition was such that the time needed to transport the enrollee 
by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously 
endangered the enrollee's health. Records document a left hip injury with shortening of the left lower extremity 
but otherwise stable vital signs and a stable neurological, cardiac and pulmonary status such that ground 
ambulance transport did not appear to be contraindicated.  
 
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 air transport have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance service, conventional air services, transport, one-way (rotary wing) A0431) and 
rotary wing air mileage, per statute mile (A0436) provided June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Zilretta is medically reasonable or necessary or safe and effective for 
you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.