Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L5 transforaminal epidural injection services. 
 
You asked the Plan to pre-approve additional transforaminal epidural injection services. You say that this is 
medically necessary for your pain management. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than 2 transforaminal epidural injection 
services should be performed at a single setting (e.g., single level bilaterally or two levels). 
 
We looked at the file and Medicare rules. In this case, the Plan has already agreed to coverage of 2 
transforaminal epidural injection services. Additional injection services will not be covered on the date in 
question. Based on this information, we decided that Medicare rules for coverage of additional transforaminal 
epidural injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
bilateral L5 transforaminal epidural injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flex-walk system (CPT code L5981 and L5968). 
 
You asked the Plan to pre-approve the flex-walk system. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not 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 flex-walk system. Our physician 
reviewer found the flex-walk system represented by code L5981, and L5968 multi axial ankle with swing phase 
exceeds your medical needs and are not medically necessary per LCD: Lower Limb Prostheses (L33787) and 
per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). The treating medical provider 
progress notes do not support the prosthetist (vendor) claims that you are a K3 ambulator. You were also 
recently approved for a power wheelchair to assist in mobility-related activities of daily living (MRADLs) 
which does not support K3 ambulatory level. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the flex-walk system (CPT code L5981 and L5968).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve conscious sedation (D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that when you signed up for this plan you were 
advised all services would be approved. You say that the plan owes you something. You also say that sedation 
should be covered for your extractions. The Plan denied your request. The Plan says the claim 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested sedation services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
conscious sedation (D9239, D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have exhausted the established benefit of 48 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (code D0460) and the interpretation of 
diagnostic image (code D0391) you received on January 26, 2022. 
 
You asked the Plan to pay for the pulp vitality test (code D0460) and the interpretation of diagnostic image 
(code D0391). You say that you first went to a different endodontist but the procedure had to be cancelled due 
to your blood pressure and temperature.  You said that you went to a second endodontist who had to read the 
Computed Tomography (CT) scan you had previously, so this should be covered. The Plan denied your 
request. The Plan says these services are not covered under your dental benefit. 
 
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. Your Plan's dental benefit 
includes coverage only for those dental services explicitly listed in your Dental Benefits chart. Neither code 
D0460 nor code D0391 are listed as covered dental services.  This means that these codes are not covered for any reason. 
 
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 pulp 
vitality test (code D0460) and the interpretation of diagnostic image (code D0391) you received on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablets. 
 
You asked the Plan to pre-approve Ubrelvy tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Ubrelvy tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Ubrelvy tablets.  
 
Benefits for Ubrelvy tablets 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 pre-approve adult day care services. 
 
You asked the Plan to pre-approve adult day care services. The Plan denied your request. The Plan says adult 
day care is not a covered benefit. 
 
The Plan contract does not provide coverage for adult day services. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover adult day care services. 
Therefore, we decided that the Plan does not have to pre-approve adult day care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you need an extraction and a bone graft. 
The Plan denied your request. The Plan says bone replacement graft for ridge preservation 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 requested bone replacement graft 
for ridge preservation is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve bone replacement graft for ridge preservation (D7953).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional physical therapy visits. 
 
You asked the Plan to pre-approve 9 additional physical therapy visits. You say that these services are 
medically necessary. The Plan denied your request. The Plan says additional physical therapy beyond what has 
been approved is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 9 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of your condition. Our physician reviewer found that based on the medical records provided there is no 
documentation that the requested therapy is generally accepted as specific and effective therapy for your 
condition. Based on the available records you appear to have improved with therapy to the point of being able 
to manage ambulation without an assistive device and activities of daily living more independently. After your 
previously approved therapy treatments plus the additional 15 visits recently approved, records do not support 
that the complexity of your conditions are such that the skills of a professional therapist will likely be required 
to achieve further improvement in the patient's symptoms or functional status. Further utilization of the home 
exercise program appears appropriate after completion of the recently approved 15 additional therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller represented by code E2377, a 
harness represented by code E2313, and an electrical connection represented by code E2311. 
 
You asked the Plan to pre-approve codes E2377, E2313, and E2311. You say that the enrollee meets all 
necessary criteria for coverage for the items which remain in dispute. The Plan denied your request. The Plan 
says the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power 
options using their own switches which are included in the allowance of these power options. 
 
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 codes E2377, E2313, and E2311. Our reviewer says that the items which remain in dispute are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is inconsistent documentation with regard to the enrollee's level 
of weakness and disability. The vendor reports that the enrollee cannot ambulate and has 0/5 left hand strength 
and 1/5 right hand strength whereas a medical visit note of February 28, 2022, just reports she has "some left 
sided residual weakness and trouble walking safely with a cane or walker." The only strength deficit reported 
on the physical examination at the time of the February 28, 2022, visit was "motor strength mildly decreased on 
left side (upper and lower)." Given the lack of detail and the inconsistencies in the records it is not clear that the 
expandable controller (E2377), harness (E2313) and electrical connection (E2311) at issue in this case meet 
Medicare criteria for 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 codes E2377, E2313, and E2311 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller represented by code E2377, a harness 
represented by code E2313, and an electrical connection represented by code E2311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7210, D0140, D9222) provided on 
August 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe these charged qualify for 
reimbursement. The Plan denied your request. The Plan says these services are not covered by Medicare or by 
the Plan's supplemental dental insurance. 
 
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 the dental 
services (D7210, D0140, D9222) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam - four or more surfaces, primary or permanent 
(D2161) provided February 28, 2022. 
 
You asked the Plan to pay for the amalgam. You say that you were not aware that your plan had changed. The 
Plan denied your request. The Plan says this service is not covered under your benefits. The Plan also says that 
their records show that an Annual Notice of Change was mailed to you. 
 
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 the 
amalgam - four or more surfaces, primary or permanent (D2161) provided February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adempas. 
 
You asked the Plan to pre-approve Adempas. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
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 Adempas.  
 
Benefits for Adempas 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the carboplatin (J9045), Paclitaxel (J9267), and Zirabev 
(Q5118). 
 
You asked the Plan to pre-approve the carboplatin (J9045), Paclitaxel (J9267), and Zirabev (Q5118). You say 
that the drugs are medically necessary. The Plan denied your request. The Plan says the drugs are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 carboplatin (J9045), Paclitaxel 
(J9267), and Zirabev (Q5118). Our reviewer says that the drugs are not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of EGFR mutated metastatic non-small 
cell lung cancer.  The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's specific clinical condition.  The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's specific clinical situation. 
 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 carboplatin (J9045), Paclitaxel (J9267), and Zirabev (Q5118) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the carboplatin (J9045), Paclitaxel 
(J9267), and Zirabev (Q5118).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot be managed at home or at a skilled nursing facility. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure, congestive heart failure, myocardial infarction, and acute renal insufficiency. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a water circulating cold pad with pump. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a water circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a water circulating cold pad with pump (E0218).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MLH1 (mutL homolog 1, colon cancer, nonpolyposis 
type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis coded 81292 provided 
on August 9, 2021. 
 
You asked the Plan to pay for the MLH1 gene analysis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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.  
In this case, the CPT Code Manual definition of code 81292 is MLH1 (mutL homolog 1, colon cancer, 
nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full 
sequence analysis. 
 
We find that CPT code 81292 is not supported in the medical record. Specifically, when a laboratory assays 
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file 
does not support that only one code was billed for the panel provided. Based on this information, we decided 
that Medicare rules for coverage of the MLH1 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for the MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary 
non-polyposis colorectal cancer, Lynch syndrome) gene analysis coded 81292 provided on August 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 6, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were discharged from the ER 
and had to return hours later. You say that this should be considered one visit. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 an emergency room (ER) visit 
provided on March 6, 2022.