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

 
We decided that the Plan does not have to pay for the extractions (D7210), the parenteral drugs (D9612), and 
the sedation (D9223) for tooth #13, #14, #15, #21, #22, #23, #24, #25, #26, #27, #28, and #29 provided on 
August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your benefit for the extractions has already been exhausted. the 
denial of payment for the parenteral drugs and sedation is correct, because they are 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 Plan's 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 for the extractions was exhausted on the date of service of August 10, 2022. The parenteral 
drugs and sedation are not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not 
have to pay for the extractions (D7210), the parenteral drugs (D9612), and the sedation (D9223) for tooth #13, 
#14, #15, #21, #22, #23, #24, #25, #26, #27, #28, and #29 provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture services to be provided by a 
non-contracted provider (NCP). 
 
You asked the Plan to pre-approve the acupuncture services. You say that you need acupuncture at least four 
(4) times a month because of a concussion which causes you to have severe headaches, and severe pain in the 
chest. The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the acupuncture services have been 
met. Medical records were not provided to verify if the services are necessary. Therefore, we decided that the 
Plan does not have to pre-approve additional acupuncture services to be provided by a non-contracted provider 
(NCP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says it has not been three months since the last injection.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the most recent injection was on 10/25/2022. It has not been three months since the last injection.

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 a repeat epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections at a third level. 
 
You asked the Plan to pre-approve facet joint injection at a third level. You say that the injection will only be 
performed at two levels. The Plan denied your request. The Plan says a third level injection is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that he need for a three or four-level procedure 
bilaterally may be considered under unique circumstances and with sufficient documentation of medical 
necessity on appeal. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of facet joint injection at the third level have not been met. Specifically, the provider is only 
performing injections at two levels. Therefore, we decided that the Plan does not have to pre-approve facet 
joint injections at a third level.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital day discharge services provided to the enrollee on March 31, 2022.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Original Medicare would be responsible for payment.

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 hospital day discharge services provided to the enrollee on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on April 5, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement for the claim. The 
Plan denied your request. The Plan says the provider was out-of-network. 
 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 services are provided by the network vision provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyewear provided on April 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flextouch U-100. 
 
You asked the Plan to pre-approve Tresiba Flextouch U-100. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tresiba Flextouch U-100.  
 
Benefits for Tresiba Flextouch U-100 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and administration 
(90471) provided on September 15, 2021. 
 
You asked the Plan to pay for the vaccination. You say that the provider billed the wrong insurance. You say 
that this vaccination is covered under your plan. The Plan denied your request. The Plan says the shingles 
vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccination. 
Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and 
administration (90471) provided on September 15, 2021.  
 Benefits for the vaccination 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 waive the copayment for CT scan provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were told that your copayment 
would be $20. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $102.10, which is less than the $125 copayment for CT scan. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayment for CT scan provided on April 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study at a sleep center (95810). 
 
You asked the Plan to pre-approve a sleep study at a sleep center. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service 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 a sleep study at a sleep center. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no impediments to a home sleep study, and you have been 
approved for that test.  
 
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 sleep study at a sleep center have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sleep study at a sleep center (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nitro Rollator. 
 
You asked the Plan to pre-approve the Nitro Rollator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that there is no medical necessity for specific brand. 
 
The Plan must follow Medicare rules. Medicare rules say that if durable medical equipment serves the 
same purpose as equipment already available to the member, it is not considered reasonable and necessary.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Nitro Rollator have not been met. Specifically, you were approved a regular walker, there is not 
medical necessity for a brand specific walker. Therefore, we decided that the Plan does not have to pre-approve 
the Nitro Rollator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve the requested item. You say that you have a hard time moving. The Plan 
denied your request. The Plan says you do not meet the requirements. 
 
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.  
 
The file does not show that your condition cannot be improved by a walker, cane or manual wheelchair. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not receiving care at their home, and 
they currently live alone. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can receive the care they need in another setting. 
 
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 enrollee does not have any active medical issues or complex functional 
impairments thus the complexity of the patient's documented nursing, medical and rehabilitation needs would 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided on July 17, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you are requesting reconsideration of the 
denied charges. The Plan denied your request. The Plan says the routine disposable supplies are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies provided on July 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the formal 
magnetic resonance imaging (MRI) read does not demonstrate any Modic changes at the requested surgical 
level. There were/are multiple plausible pathologic sources of significant pain generation. The back pain, the 
noted pain-aggravating factors (bending/twisting, standing, walking, and exercises), pain-relieving factors 
(laying and sitting), the diminished spinal motion (in all directions), and intact neurologic exam were/are all 
non-specific to any pathologic entities. Overall, documentation was/is lacking regarding reasonably detailed 
and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at 
L5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an XPro lightweight folding electric wheelchair. 
 
You asked the Plan to pre-approve an XPro lightweight folding electric wheelchair. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says your current wheelchair is 
less than 5 years old. The Plan says they have approved an evaluation of your current wheelchair and for any 
necessary repairs.  
The Plan must follow Medicare rules. Medicare rules say that payment may be made for repairs to equipment 
up to the cost of replacement. Replacement may only be covered during the 5-year useful life when there is a 
specific incident which damages the item beyond repair. Replacement from wear from day-to-day activities is 
not covered within the 5-year lifetime. 
 
In this case, your current wheelchair has not been examined or evaluated to support that it is not working 
properly. The file shows that the Plan has approved an evaluation of your current wheelchair and for any 
necessary repairs. The file shows that your current wheelchair is less than 5 years old, and you are not eligible 
for a new one until May of 2023. Replacement cannot be provided without objective evidence that the current 
wheelchair is damaged or not working. Based on the lack of any actual documentation of damage, replacement 
cannot be considered necessary at this time. Therefore, we decided that the Plan does not have to pre-approve 
an XPro lightweight folding electric wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 and 88360 billed for date of service 
March 8, 2022. 
 
You asked the Plan to pay for procedure code(s) 88381 and 88360. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that these codes are 
included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381 and 88360. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88381 and 
88360. Based on this information, we decided that Medicare rules for coverage of procedure code 88381 and 
88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88381 and 88360 billed for date of service March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180) provided on June 14, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation - new or established patient (D0180). 
You say that the referring provider sent you to a dentist who is out-of-network. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation - new or established patient (D0180) provided on June 14, 2022.