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

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (dental code D6106). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that the enrollee is at risk of losing 
teeth. The Plan denied your request. The Plan says this service is not covered by the Plan. 
 
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 
guided tissue regeneration (dental code D6106).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiation oncology services provided on September 21, 2022, and 
September 22, 2022. 
 
You asked the Plan to pay for radiation oncology services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the number of services billed exceeds the number allowed 
within the course of treatment. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for radiation oncology services 
provided on September 21, 2022, and September 22, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for an 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but requires additional short-term acute care 
services that can safely be provided at the current facility until more stable and appropriate for a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current facility. 
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87634, 87640 and 87798) provided on June 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that initially, no medical records 
were provided for these services. 
 
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. Specifically, medical records for these services have been provided. Therefore, 
we decided that the Plan has to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87634, 87640 and 87798) provided on June 11, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low air mattress (E0277). 
 
You asked the Plan to pre-approve low air mattress. You say that the enrollee's medical history shows that they 
have had sever bed sores and other ailments that come from prolonged use of a bed. You say that the doctor 
sees it as medically necessary as a means to preventive care. The Plan denied your request. The Plan says the 
requested low air mattress is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a group 2 support surface may be covered if the 
beneficiary meets certain criteria. 
 
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 low air mattress. Our reviewer says that 
a low air mattress is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee requires assistance with mobility and performing daily activities. The reviewer found 
there is limited clinical history regarding the enrollees level of function with bed mobility and risk for the 
development of pressure sores. The reviewer found that the physical examination does not indicate that the 
enrollee has areas of skin breakdown. Therefore, the reviewer found that the requested low air mattress is not 
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 low air mattress have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a low air mattress (E0277).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the anesthesia services provided on October 26, 
2022. 
 
You asked the Plan to waive the coinsurance for the anesthesia services. You say that the anesthesia charges 
should be included in the surgical center charge. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
You have been asked to pay 20% coinsurance for the anesthesia services. According to Medicare, the 
anesthesia services (code 00840) is considered a packaged code and is not separately payable. Therefore, we 
decided that the Plan has to waive the coinsurance for the anesthesia services provided on October 26, 2022.  
 
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 pre-approve the lumbar or sacral epidural injection (64483). 
 
You asked the Plan to pre-approve the injection. You say that the epidural shots in your spine took away some 
of the pain. you are in a lot of pain and cannot function. The Plan denied your request. The Plan says the 
records do not show improvement in pain relief and/or improvement in function measured from baseline using 
same scale for at least 3 months. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had Epidural Steroid injections in November 2022 and December 2022, which 
gave 50-60% pain relief for 2 weeks. The LCD criteria is 50% for 3 months. There is other evidence-based 
therapies available to this enrollee. The request does not meet the LCD criteria and therefore, is deemed not 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar or sacral epidural injection (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on January 05, 2023. 
 
You asked the Plan to pay for a chiropractic visit. You say that you were unaware that this provider was out-of-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on January 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on April 6, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
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 April 16, 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 radiology services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for radiological services provided on April 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a root tip extraction. We decided that the Plan does not have to 
pre-approve additional extractions.  
 
You asked the Plan to pre-approve root tip extraction and surgical extractions. You say that you would like the 
plan to approve these services. The Plan says that these services have been processed correctly. 
 
We decided that the Plan has to pre-approve a root tip extraction.  
 
Therefore, we decided that the Plan has to pre-approve a root tip extraction. 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 failed to provide dental x-rays. Therefore, we decided that the Plan 
has to pre-approve a root tip extraction.  
 
We also decided that the Plan does not have to pre-approve additional surgical extractions. 
 
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, certain limitations apply. The record 
shows your benefit surgical extractions has been met and exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical extractions. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories 
(E1007, E2311, E2377, E2313, E2363, E0953, K0040, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has muscle 
spasms and does not always have assistance to help her adjust her power chair (she has a part time provider 
who does laundry and cooking). She also has a need for pressure relief and cannot shift her body, she is at risk 
for pressure sores. Clinical notes are attached and highlighted where it addresses these topics. You are asking 
for an urgent appeal because the enrollee is suffering each day that she does not have this chair and as noted in 
the clinicals that she falls regularly and is at risk for further injury. The Plan denied your request. The Plan says 
the enrollee does not have a medical need for multiple power options available with a group 3 power 
wheelchair. Expandable controller, harness and electronics are not medically needed. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
decreased strength secondary to diabetic neuropathy. She does not have skin breakdown and she is not at high 
risk for skin breakdown. She does not use intermittent catheterization and does not have significant spasticity. 
She is able to manage 18 hours a day alone. The enrollee does not require power tilt or tilt and recline as she 
does not have a condition which per L33789 is required, and as stated above from review of the records 
indicates she requires those power drives. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E1007, 
E2311, E2377, E2313, E2363, E0953, K0040, K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the pain impacts the enrollee's activities 
of daily living. The Plan denied your request. The Plan says the request is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its efficacy. 
Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Miralax, Dulcolax and Gatorade purchased on November 14, 
2022. 
 
You asked the Plan to pay for Miralax, Dulcolax and Gatorade. You say that these services were necessary for 
your colonoscopy, and therefore should be covered. The Plan denied your request. The Plan says these services 
are over-the-counter items which are not covered by Medicare and are not reimbursable by your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Miralax, 
Dulcolax and Gatorade is an OTC item. These services were not purchased from a participating retailer with 
your Plan. Therefore, we decided that the Plan does not have to pay for Miralax, Dulcolax and Gatorade 
purchased on November 14, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. 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 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 Entyvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that a family member recently passed away from 
aggressive cancer, and you need to know if you are at risk due to family genetics. The Plan denied your 
request. The Plan says this test is not covered when it is provided as a screening to an enrollee with no personal 
history of cancer. 
 
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, genetic testing, is being requested solely for screening purposes as it is 
requested for an enrollee with no personal history of cancer and no current symptoms. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer next-generation sequencing (NGS) 
panel 
 
You asked the Plan to pay for the colorectal cancer (NGS) panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this service was not medically necessary to treat a 
disease or injury. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the colorectal cancer (NGS) panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the colorectal cancer next-generation sequencing (NGS) panel
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be met at a 
skilled nursing facility as they are currently on a wound vacuum and requires wound care. You say that the 
enrollee's needs physical therapy to gain mobility. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee requires short-term additional acute care services that can be 
provided safely at their current facility until they are more stable. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.