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

 
We decided that the Plan does not have to pay for the filling (D2331) provided on July 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why at least a portion of 
the bill was not paid. You say that most plans cover preventive care. You also say that you feel like something 
should have been paid. The Plan denied your request. The Plan says the provider in this case is out of network. 
The Plan also says that dental services received 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the 
Evidence of Coverage clearly states that services obtained from vendors outside this network are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling 
(D2331) provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you still have problems with your teeth even 
after receiving these services. The Plan denied your request. The Plan says you have exhausted your annual 
dental benefit, so 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. The Plan's rules state that you 
have a $1500 per year allowance for dental services, and you are responsible for any amounts over the 
allowance.  Records show that you exhausted this yearly allowance with dental services you received on 
November 20, 2021. Therefore, we decided that the Plan does not have to pay for dental services you received 
on December 9, 2021.  
 
Your complaint about the dental services not being necessary is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee's upper limb strength and function are adequate enough to control the power options using their own 
switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that a power seat elevation system. We looked at the file and the rules. This feature is non-
covered because it is not primarily medical in nature.  
 
The file also shows that an expandable control system was requested. 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 requested items. Our physician reviewer found that the enrollee has a 
past medical history of multiple sclerosis and diabetes with difficulty walking and multiple falls. He requires a 
power wheelchair for mobility. The provided records document that he has 4-/5 to 4/5 upper extremity strength 
and is independent with feeding, grooming and dressing, thus indicating he has adequate upper extremity 
strength and function to operate the wheelchairs power options with their own switches. 
 
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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve wheelchair accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee requires this drug. The Plan denied your 
request. The Plan says that the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Our office was able to confirm that the enrollee was not enrolled in Medicare Part A when 
the enrollee received the related transplant. The self-administered drug requested here is not among the types 
which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 
Tacrolimus for the enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 3, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 3, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 3, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of May 3, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond May 3, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 3, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 3, 2022, 
forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 30, 2020. 
 
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 testing is not covered.  
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 was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy to be ambulatory 
again. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve these services. You say that it is difficult for you to get around because of 
your pain. The Plan denied your request. The Plan says that medical studies do not show this works better than 
other treatments or surgery. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for your medical condition. Our physician reviewer 
found that your condition does not meet criteria for coverage of these services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Coflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you had a previous left knee 
surgery and need the device being requested. You say that the requested device is medically necessary and 
should be covered by the Plan. The Plan denied your request. The Plan says the requested device would be used 
for preventive services and is excluded from coverage under Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivigen allograft. 
 
You asked the Plan to pre-approve the Vivigen allograft. You say that this is medically necessary for the 
enrollee's surgery. The Plan denied your request. The Plan says the Vivigen allograft is considered 
investigational. 
 
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 Vivigen allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 68-year-old female being treated for spondylosis without 
myelopathy or radiculopathy. She presented with low back pain and a sense that her legs go numb. On 
occasion, she has fallen. Exam revealed slightly reduced lumbosacral motion. Straight leg raising creates tightness 
in her back and legs, worse on the right. External rotation of the hips is uncomfortable and again 
worse on the right. She has difficulty standing from a chair, and with heel and toe standing. She has been 
approved for L4-S1 lumbar decompression and instrumented posterior lateral arthrodesis.  
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the request for Vivigen allograft (20930) 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 Vivigen allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vivigen allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an accident. You say that the services 
you received were a result of the accident. You also say that the services should be covered. The Plan denied 
your request. The Plan says the crown and core build up are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the crown for tooth #19. 
 
You asked the Plan to pre-approve the crown. You say that you do not understand why this is not considered 
medically necessary. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted digital copies of the dental x-rays used to make this 
decision. We requested these from the Plan and have not received a response. Without x-rays, we cannot 
confirm whether coverage criteria have been met. Therefore, we decided that the Plan has to pre-approve the 
crown for tooth #19.  
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided October 7, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim was originally sent to 
workers comp in error, but it was not workers comp related. Kindly review and reprocess this claim for 
reimbursement. The Plan denied your request. The Plan says the claim was received past the timely filing 
limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent hospital care was not filed until December 15, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided 
October 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on December 31, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that the services should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
 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 for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the inpatient hospital care provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that this dental care is necessary at this time. 
The Plan denied your request. The Plan says the requested services are not medically necessary as the tooth in 
question does not have significant breakdown due to decay or trauma. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested dental care is not medically reasonable and necessary. Our physician reviewer found an 
appeal is being made for the denial of coverage for a core buildup (D2950) and crown (D2740) for tooth #31.  
The documentation provided does not indicate significant coronal breakdown due to caries or fracture of tooth 
#31.  There was no narrative indicating the reason for the core buildup and 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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup (D2950) and crown (D2740) for tooth #31.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fine needle aspiration biopsy (10005) provided on 
November 10, 2021. 
 
 
 
 
 You asked the Plan to pay for the fine needle aspiration biopsy. You say that you disagree with this denial, as 
this is a payable service with a medically unlikely edit (MUE) indicator of 1 and no frequency issues. The Plan 
denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 60100 and 10005. This PTP edit has a modifier indicator of 1, meaning modifiers 
associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 10005 
is a column II code to column I code 60100. 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 fine needle aspiration biopsy (10005) provided on November 
10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided by an 
out-of-network provider on October 21, 2021. 
 
You asked the Plan to pay for unspecified preventive procedure. You say that you do not feel like you should 
have to pay for the PPE. The Plan denied your request. The Plan says D1999 is not a covered dental 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 an 
unspecified preventive procedure (D1999) provided by an out-of-network provider on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on July 20, 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 services are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only from a provider. 
 
We looked at the file and the Plan's rules. The file shows that you received hearing aids from a provider that is 
not a specific provider. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aids purchased on July 20, 2021.