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

We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R interspinous device
and stability biologics allograft.
You asked the Plan to pre-approve implantation of the Minuteman G3R interspinous device and stability
biologics allograft. You say that the services are necessary. The Plan denied your request. The Plan says
medical necessity has not been established. Therefore, coverage criteria have not been met.
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 implantation of the Minuteman G3R
interspinous device and stability biologics allograft. Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found 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 implantation of the Minuteman G3R
interspinous device L4-L5 and stability biologics allograft 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 implantation of the Minuteman G3R interspinous device and stability biologics
allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of
the Minuteman G3R interspinous device and stability biologics allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and intraoral x-ray (D0220) 
provided on October 6, 2021. 
 
You asked the Plan to pay for the limited exam and x-ray. You say that you were referred to this provider 
because they were the only one able to perform these necessary services in a reasonable time frame. The Plan 
denied your request. The Plan says they have agreed to pay for the root canal because there is evidence that you 
were referred to this dentist by a contracted provider. However, the limited oral exam and intraoral x-rays 
remain denied as these are not covered services, regardless of the network status of the rendering provider. 
 
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 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 limited oral exam (D0140) and intraoral x-ray (D0220) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported removable partial denture (D6113) 
provided on October 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not have good tissue and bone to function 
with a full bottom denture. You say that you chose implants so that you would be able to chew your food. You 
also say that you feel that some of this should be covered. The Plan denied your request. The Plan says implant 
supported removable partial denture is not listed as a covered service. 
 
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 implant supported removable partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the implant supported removable partial denture (D6113) provided on October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you cannot ambulate more than 30 feet. You say 
that your house is not handicap equipped and you cannot go upstairs. You say that you are at risk of falling. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of SNF 
care. The Plan says that the therapy the enrollee needs can safely be received at a different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
patient requires skilled nursing services. Records do not document the need for intravenous medications, new 
tube feeding, or ostomy care or daily complex wound care. The enrollee does require skilled therapy services, 
but not on a daily basis. There is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 29, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you believe that POS 81 is correct for this 
lab testing. The Plan denied your request. The Plan says the POS code does not match the location where the 
sample was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal scaling and root planing (D4341) provided by a 
participating provider on November 4, 2021. 
 
You asked the Plan to pay for a periodontal scaling and root planing. You say that for some reason your 
insurance was cancelled. You say that you should not have to pay for this. The Plan denied your request. The 
Plan says the dental services that were provided 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 Plan's 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 
periodontal scaling and root planing (D4341) provided by a participating provider on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on 
October 12, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had a tooth causing you pain. You say that 
you could not get an appointment with an in network dentist. You say that the dentist you found was able to 
save your tooth with a stainless steel crown to save on costs. You also say that you would like this to be 
covered. The Plan denied your request. The Plan says prefabricated stainless steel crown is not listed as a 
covered service. 
 
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 prefabricated stainless steel crown 
is not among those covered under this benefit, regardless of the provider's network status. Therefore, we 
decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on 
October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure. Therefore, the request is deemed 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgeries provided on October 19, 2020, and November 2, 2020.
You asked the Plan to waive the copayments for cataract surgeries. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $375 copayment for each ambulatory surgical center service, except those done during a colorectal screening. You have been asked to pay a total of $750, which a $375 copayment for each cataract surgery ($375 copayment + $375 copayment = $750). Cataract surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. 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 copayments for cataract surgeries provided on October 19, 2020, and November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodontal maintenance (D4910) 
provided October 28, 2021. 
 
You asked the Plan to provide additional payment for the periodontal maintenance. You say that you feel you 
were only given a basic cleaning. The Plan denied your request. The Plan says this claim has processed 
correctly. 
 
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 
periodontal maintenance with 30% coinsurance.  
 
We looked at the file and Medicare rules. You have been asked to pay $24.90 ($83 maximum contract 
allowance x 30% coinsurance = $24.90). 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 provide additional payment for the 
periodontal maintenance (D4910) provided October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator with settings that could be delivered by bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this enrollee with chronic obstructive pulmonary disease (COPD) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the Life2000 System is not medically necessary.
This system is not a true ventilator, because it is not capable of providing full ventilatory support. The enrollee has severe COPD, and had COVID-19 pneumonia a few months ago. There is no arterial blood gas (ABG) study documenting C02 retention. The enrollee has already been provided with a home ventilator for use during sleep, which she has not used. The Life2000 system has not been shown to be beneficial in the treatment of COPD, in controlled clinical trials. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 Vertiflex 
Superion interspinous device at L4-5 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the patient 
requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The 
enrollee's needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 6 periapical x-rays provided on November 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went for a regular check up and cleaning. 
You say that you did not ask for all of the x-rays. You say that you told them you only wanted to get what your 
insurance covered. You also say that these charges should be removed from your account. The Plan denied 
your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the 
frequency limit has been exceeded. 
 
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 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 1 additional 
periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does 
not have to pay for the 6 periapical x-rays provided on November 22, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a computed tomographic angiography (CTA) scan of the chest (71275)
provided on August 28, 2021.
You asked the Plan to pay for a CTA scan of the chest. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the
services at issue have not been met.
The Plan must follow Medicare rules. The rules say that angiography of the chest for non-cardiac assessment
will be considered medically reasonable and necessary for the signs or symptoms of disease listed 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 pay for a CTA scan of the chest. Our reviewer says
that the services at issue are considered medically reasonable and necessary in this case. Our physician
reviewer found that the indication for the chest CTA at issue was hypoxia and pneumonia with possible
pulmonary embolism. Chest CTA coded 71275 is a valid, standard practice exam with those symptoms. The
examination was well documented in the report and meets criteria for reimbursement.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CTA scan of the chest have been met. Therefore, we decided that the Plan has
to pay for a computed tomographic angiography (CTA) scan of the chest (71275) provided on August 28, 2021.
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: Favorable

We decided that the Plan has to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 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 the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has failed conservative therapy. The request meets the LCD criteria for facet blocks. The request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections for the enrollee.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee was walking household distances with a rolling walker with minimum assistance and was contact guard assist for transfers. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Therapy services in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.