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

 
We decided that the Plan does not have to pre-approve a tooth extraction with an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction with an oral surgeon. 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. 
 
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 says covered dental 
services must be performed by a participating general dentist.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a tooth extraction with an oral surgeon have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a tooth extraction with an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (CPT code E2300) and 
the tapered foot plate cover (CPT code K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. There is a request for footplate 
accessories: K0108 footplate cover and extension These are parts are miscoded; K0108 must not be used for 
items that have a specific CPT code. Furthermore, a power seat elevation feature (E2300) and power standing 
feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (CPT code E2300) and the tapered foot 
plate cover (CPT code K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of mini implants on tooth #21, 23, 
26, and 28 (D6013). 
 
You asked the Plan to pre-approve mini implants. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says surgical placement of mini implants (D6013) is not covered by 
your dental 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 
surgical placement of mini implants on tooth #21, 23, 26, and 28 (D6013).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two dental extractions to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve two dental extractions to be performed by an oral surgeon. 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. 
 
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 says covered dental 
services must be performed by a participating general dentist.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of two dental extractions to be performed by an oral surgeon have not been met. Therefore, we 
decided that the Plan does not have to pre-approve two dental extractions to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #30. 
 
You asked the Plan to pre-approve a crown (D2740) for tooth #30. The Plan denied your request. The Plan says 
that there is no evidence of decay or missing crown to support the need for replacement. 
 
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. Medical records and x-rays were not provided for this case. We asked for these 
documents, but they were not provided to us. Without this information we cannot determine that the requested 
crown is not medically necessary. Consequently, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #30.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an Oral surgeon. 
 
You asked the Plan to pre-approve dental services to be provided by an Oral surgeon. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says supplemental dental 
services are not covered when provided by an Oral surgeon. These dental services must be provided by a 
participating general dentist. 
 
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 unless provided by a participating general dentist. The Plan does not 
provide these services when provided by an Oral surgeon. Therefore, we decided that the Plan does not have to 
pre-approve dental services to be provided by an Oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 99051. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99051 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service March 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhinoplasty surgery provided by an opted out physician 
on January 21, 2022. 
 
You asked the Plan to pay for rhinoplasty surgery provided by an opted-out physician. You say you should not 
be penalized for selecting the only appropriate surgeon for your condition. The Plan denied your request. The 
Plan says the denial of payment for the services is correct because this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
rhinoplasty surgery provided by an opted out physician on January 21, 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 enrollee meets the full criteria for an inpatient 
acute rehab stay. He is requesting inpatient acute rehab versus lesser level of care, as the enrollee requires 3 
hours of therapy a day provided by a multidisciplinary team, daily MD visits by a physiatrist to consistently 
monitor their physical and medical status. The Plan denied your request. The Plan says this is not medically 
necessary, and a lower level of care might be appropriate. 
 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 a gastrostomy tube replacement to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a gastrostomy tube replacement 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 
a gastrostomy tube replacement to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam (92014), fundus photography (92250) 
and routine eye exam (V2784, V2750, V2781, V2020) provided May 30, 2022, by an out-of-network (OON) 
provider. 
 You asked the Plan to pay for the routine vision services provided OON. You say that the provider did not 
inform you that they are OON. The Plan denied your request. The Plan says these services are not covered 
because they were provided OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided in-network. 
 
We looked at the file and the Plan's rules. In this case the services were obtained from a provider outside of the 
Plans vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the 
routine vision services provided OON have not been met. Therefore, we decided that the Plan does not have to 
pay for the routine eye exam (92014), fundus photography (92250) and routine eye exam (V2784, V2750, 
V2781, V2020) provided May 30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and immunization administration (90471) provided on June 30, 2022. 
 
You asked the Plan to pay for the Tdap vaccine and administration. You say that this is a lifesaving vaccine, 
and you were notified that you needed the vaccine. You also say that you do not think it is fair that this is not 
covered. The Plan denied your request. The Plan says these services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids 
and acellular pertussis vaccine (Tdap) (90715) and immunization administration (90471) provided on June 30, 
2022.  
 
Benefits for the Tdap vaccine and administration 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 procedure code 71045 billed for date of service March 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 76376. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76376 is bundled into 
payment for code 78226. 
 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 76376 
is a column II code to column I code 78226. 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 procedure code 76376 billed for date of service May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non/invasive, other 
than spinal applications (E0747). 
 
You asked the Plan to pre-approve osteogenesis stimulator. You say that the requested stimulation is medically 
necessary. The Plan denied your request. The Plan says the conditions documented do not meet these 
requirements and the request is therefore not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  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 osteogenesis stimulator. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding diagnostic imaging studies provided at designated/significant intervals to show that the 
second and third metatarsal fractures are non-healing. The provided CT scan was taken 14 days after the initial 
x-rays. There are limited large-scale, long-term references showing the safety and efficacy of electrical bone 
growth stimulators in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
electrical bone growth stimulator, 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 osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulator, electrical, non/invasive, other than spinal applications 
(E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulation (Dorsal Column Stimulation). 
 
You asked the Plan to pre-approve spinal cord stimulation. You say that treatment is needed for lower back 
pain after exhausting other treatment options. The Plan denied your request. The Plan says the documentation 
fails to indicate that you have one of the conditions outlined in the Local Coverage Determination (LCD) for 
spinal cord stimulation. You do not meet criteria for approval. 
 
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 spinal cord stimulation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have had 3 prior injections without sustained improvement. You do not have an 
evidence-based indication for a SCS trial. You do not meet criteria for coverage of the requested treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal cord stimulation (Dorsal Column Stimulation).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered when specific criteria 
are met. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has been slowly losing 
weight over the last year and has failure to thrive. There is no documentation supporting that the enrollee needs 
the special nutrient formula over an enteral formula consisting of semi-synthetic intact protein/protein isolates. 
The notes do not mention she has issues with other types of formulas. The services are therefore not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral nutrition.
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 you are in pain, and you cannot do any physical 
therapy. The Plan denied your request. The Plan says you do not meet the criteria for an IRF stay. 
 
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 appear to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not appear to require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation 
setting. You do not require rehabilitation nursing for parenteral nutrition or tube feedings, tracheostomy 
management or bowel and bladder management. 
 
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.