Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) additional hours per week of home health 
services (HHS) (G0156). 
You asked the Plan to pre-approve additional hours of HHS per week. You say that the requested additional 
hours per week are medically necessary. The Plan denied your request. The Plan says the requested additional 
hours per week do not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional hours of HHS per week. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not require 
additional home health aide hours to effectively provide treatment, care, and/or services in order to improve 
your condition, perform a maintenance program to maintain your condition and/or prevent deterioration.  You 
have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional hours of HHS per week have not been met. Therefore, we decided 
that the Plan does not have to pre-approve seven (7) additional hours per week of home health services (HHS) 
(G0156).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81301, and 81311) provided 
on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services (81206, 81301, and 81311). You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81301, and 81311) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the implant supported porcelain/ceramic crown. You say that you would like to 
appeal this service because the Plan does cover crowns and you are living on a fixed income. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental 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, 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 
implant supported porcelain/ceramic crown (D6065) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided by a participating 
provider on January 19, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that the Plan wants you to wait 12 months 
because you already had 2 fillings. You say that you do not agree with this. The Plan denied your request. The 
Plan says the benefit limit for D2391 has already been met and exhausted. 
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. The Plan covers two resin-
based composite per 12-month period. 
 
We looked at the file and Medicare rules. Evidence was provided to show that two D2392 were provided on 
November 10, 2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based 
composite have not been met. Therefore, we decided that the Plan does not have to pay for a resin-based 
composite (D2391) provided by a participating provider on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal injection provided on December 20, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary. Review of the progress note shows that the field for electronic signature is blank, and the only potential signature is typed and undated. In 
addition, the progress note does not have a date of service specified, meaning it cannot be confirmed that this 
note is for the services provided on the date of service at issue. Therefore, we decided that the Plan does not 
have to pay for the spinal injection provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 
13, 2021. 
 
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 this code is a status B code and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services provided to the enrollee on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal injection provided on November 1, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary. Review of the progress note 
shows that the field for electronic signature is blank, and the only potential signature is typed and undated. In 
addition, the progress note does not have a date of service specified, meaning it cannot be confirmed that this 
note is for the services provided on the date of service at issue. Therefore, we decided that the Plan does not 
have to pay for the spinal injection provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81225, 81226, 81230, 81238, 81240, 
81241, 81291, 81335, 81406, 81407, 81408, and 81479) provided on April 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81225, 81226, 81230, 81238, 81240, 81241, 81291, 81335, 81406, 81407, 
81408, and 81479) provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282, S9999) provided November 15, 2021. 
 
You asked the Plan to pay for the wig. You say that the item was medically necessary. The Plan denied your 
request. The Plan says wigs are not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282, S9999) 
provided November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2751, D2954, D3330). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says treatment is denied due to furcation involvement. 
 
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 services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that a review of the 
documentation indicates that the bone support of tooth #30 is poor and the prognosis for retention is poor. The 
services requested do not appear to be medically reasonable due to a poor prognosis for the retention of the 
tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D2751, D2954, D3330).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the PET with concurrently acquired CT for attenuation correction 
and anatomical localization imaging; skull base to mid-thigh (CPT code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that you need the scan to see how much more the 
cancer has spread. The Plan denied your request. The Plan says that a PET scan is not covered for initial 
treatment strategy (finding extent of the disease) of prostate cancer. 
 
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 PET scan. Our physician reviewer 
found PMSA PET CT is indicated for men with suspected metastasis who are eligible for initial definitive 
therapy; therefore, the are criteria met. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a deep brain stimulation device. 
 
You asked the Plan to pre-approve deep brain stimulation. You say that the potential of this is worthwhile to 
improve the enrollee's quality of life. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because deep brain stimulation is not covered for enrollees with cognitive 
impairment, dementia, or depression which would be worsened by or would interfere with the ability to benefit 
from deep brain stimulation. 
 
The Plan follows Medicare rules. Medicare rules state that implantation of a deep brain stimulator for 
Parkinsons disease is not reasonable and necessary for enrollees that meet certain exclusion 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 deep brain stimulation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for deep brain stimulation. Our physician reviewer 
found the enrollee does meet some of the requirements for deep brain stimulation, particularly those for 
Parkinson's disease. However, the enrollee's neuropsychological testing revealed a major neurocognitive 
disorder which was consistent with dementia. The enrollee has a 90% risk post-procedure of having a 
worsening mental status post deep brain stimulator placement. This is an exclusion from coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of deep brain stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a deep brain stimulation device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health physical therapy (PT) visits 
(G0151). 
 
You asked the Plan to pre-approve additional home health PT visits. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health PT visits. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not have documented, ongoing, home health PT needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 6 additional home health physical therapy (PT) visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 5, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like to appeal this service 
on the basis that the Plan has failed to get the facts of your claims correctly. The Plan denied your request. The 
Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not 
contact the Plan prior to the date of service to verify benefits and provider eligibility. 
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 
periodontal maintenance (D4910) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes 
(D9222) and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that you would like anesthesia 
covered. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve deep 
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 
15 minute increment (D9223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on October 19, 2021. 
 
You asked the Plan to pay for the laboratory services (81479). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 81479, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (81479) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4). 
 
You asked the Plan to pre-approve the gingival irrigation. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says gingival irrigation 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 requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921 x 4).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that the enrollee requires additional skilled nursing services to provide treatment that is 
medically necessary. The enrollee does not require additional skilled nursing services to effectively provide 
treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance program to 
maintain the members condition and/or prevent deterioration. The enrollee has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services 
are 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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health skilled nursing visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on July 
26, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the calendar year maximum has already been met. 
 
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. The Plan covers a $1,000 
combined allowance for supplemental preventive and comprehensive dental services every year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the combined maximum 
allowance amount was already met and exhausted. Based on this information, we decided that the Plan's rules 
for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a participating provider on July 26, 2021.