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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee's condition is causing pain. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred products. 
 
 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 Euflexxa. Our physician reviewer found 
that the enrollee has bilateral osteoarthritis of the knee. The enrollee has not trialed Orthovisc, Synvisc or 
Synvisc-One. Step therapy, as outlined by the Plan, requires that these be trialed first. The documentation does 
not outline contraindications or reasons these medications were not considered or that the Plans required drugs 
would likely be less effective or likely have adverse effects for the enrollee. Without the support of the 
documentation, Euflexxa is not approved as step 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement to include these tests in the dialysis rate. The Plan denied your request. The Plan says Medicare does 
not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on May 17, 2022, billed 
with code 75710. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that all codes should be paid. The 
Plan denied your request. The Plan says the use of the modifier to bypass the edit is not supported.  
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 75710 is a column II code to column I code 37229; however, 75710 
was billed with a modifier.  
 
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 as billed. Our reviewer says that the 
documentation does not support separate payment for code 75710. Our reviewer found the record shows that 
the angiogram provided was done during a revascularization procedure, and therefore, the revascularization 
procedure includes operative angiograms and/or venograms. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the angiography services provided on May 17, 2022, billed with code 75710.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (97597) provided on January 18, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is 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 code 97597 is not supported in the medical record. Specifically, this service is included in the 
10 day global surgery period for code 36589 that was billed on January 11, 2022. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services (97597) provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - porcelain/ceramic tooth #30 (D6245), and retainer 
crown - porcelain/ceramic for tooth #'s 29 and 31 (D6740) provided on June 30, 2022. 
 
You asked the Plan to pay for pontic - porcelain/ceramic tooth #30 (D6245), and retainer crown - 
porcelain/ceramic (D6740) for tooth #'s 29 and 31. You say that the Plan told you the service would be 
covered.  The Plan denied your request. The Plan says these services are not covered under the 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 pay for pontic - 
porcelain/ceramic tooth #30 (D6245), and retainer crown - porcelain/ceramic for tooth #'s 29 and 31 (D6740) 
provided on June 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Isto Biologics Influx Sparc Allograft (CPT code 20931). 
 
You asked the Plan to pre-approve the allograft. You say that the allograft is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Isto Biologics Influx Sparc Allograft in the 
setting of anterior cervical spine fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found safety and efficiency has not been successfully demonstrated in peer-reviewed literature. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Isto Biologisc Influx Sparc Allograft in the setting of anterior 
cervical fusion, in this case, is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Isto Biologics Influx Sparc Allograft (CPT code 20931).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported crown (D6058) provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that these services are medically necessary. The Plan denied your request. The Plan says the requested services 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
custom fabricated abutment (D6057) and an abutment supported crown (D6058) provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) provided by an out-of-
network provider on February 3, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you believe the Plan should pay for more. 
The Plan denied your request. The Plan says the rendered dental 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 pay for a cone 
beam CT capture (D0364) provided by an out-of-network provider on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dental extraction (D7210) provided on 
May 18, 2022. 
 
You asked the Plan to waive the coinsurance for the dental extraction. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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 waive the 
coinsurance for the dental extraction (D7210) provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system provided from July 19, 
2021, through July 25, 2021, billed with 14 units of code A4305. 
 
You asked the Plan to pay for the disposable drug delivery system. You say that this claim should be paid in 
full for the services rendered. The Plan denied your request. The Plan says all services were approved to be 
paid, but code A4305 is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a disposable drug delivery system coded as 
A4305 is not covered by Medicare as it is not considered durable medical equipment. Therefore, we decided 
that the Plan does not have to pay for the disposable drug delivery system provided from July 19, 2021, through 
July 25, 2021, billed with 14 units of code A4305.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dental services (D5650, D7140, D0210, 
D0140) provided from January 13, 2022 to March 21, 2022 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the charges and thought the provider was in-network. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided by the out-of-0network dentist. 
These cost-sharing obligations are contractual and therefore cannot be waived. 
 
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 waive the 
copayment for dental services (D5650, D7140, D0210, D0140) provided from January 13, 2022 to March 21, 
2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mouth guard (D9944). 
 
You asked the Plan to pre-approve the mouth guard (D9944). You say that you have pain and swelling in your 
mouth and your dentist says you need the mouth guard to prevent grinding. The Plan denied your request. The 
Plan says the 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 mouth guard (D9944) is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the mouth 
guard (D9944).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram and digital breast tomosynthesis 
rendered on May 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 28, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammogram and digital breast tomosynthesis 
rendered on May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the member requires therapy that can be provided within the 
member's network. Services were not emergent/urgent for this chronic condition. The member has already 
started hand therapy with the in-network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
occupational therapy to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for white glass with high gold content crown (D2750). 
 
You asked the Plan to pay for dental services. You say that replacing the current crown with a new one is 
medically necessary. The Plan denied your request. The Plan says it is not medically necessary to replace the 
cap on your tooth. 
 
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 dental 
services when the services are medically necessary and reasonable. Crown-porcelain fused to high noble metal: 
Benefit limitation: one per 60-month(s) per patient per tooth, crown include any necessary core buildup; 
Documentation required: pre-operative x-ray(s) (D2750). 
 
  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 dental services. Our physician reviewer 
found the documentation provided does not meet the criteria for coverage for a replacement crown (D2750) for 
tooth #30. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for white glass with high gold content crown (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve a complete denture - maxillary (D5110), and complete denture - mandibular 
(D5120). You say that all your teeth have gone bad and you are getting them pulled and will be needing 
dentures. The Plan denied your request. The Plan says these services are not covered under the 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 denture - maxillary (D5110), and complete denture - mandibular (D5120).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail zoledronic acid OR have a history of osteoporosis-related fracture.

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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. 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. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74018) provided on April 16, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a correct place of 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. 
 
We find that CPT code 74018 is not supported in the medical record. Specifically, the claim was billed with 
place of service 22 (outpatient), however the records show the enrollee was an inpatient at the time this service 
was provided. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74018) 
provided on April 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
lower left quadrant and lower right quadrant. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the enrollee would benefit greatly 
from the scalings and planings. The Plan denied your request. The Plan says the medical records provided did 
not include evidence of significant bone loss. 
 
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 scalings 
and planings 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 scalings and planings. Our reviewer 
says that based on the documentation submitted, the requested dental services are not medically reasonable and 
necessary. Our physician reviewer found the enrollee does not meet Plan criteria for the requested scaling and 
root planing for four or more teeth in the lower left and right quadrants. In order to qualify, there must be a loss 
of clinical attachment on four or more teeth in any one quadrant and/or root surface calculus. Our reviewer 
found that this is not seen in the present case, with only one or two areas of bone loss seen in any one quadrant. 
 
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 scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the lower left quadrant 
and lower right quadrant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says since the drug is being dispensed by a pharmacy, it is not eligible for coverage 
under the Part B medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc.  
 
Benefits for Orthovisc may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.