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

 
We decided that the Plan does not have to pre-approve the Intracept procedure L4-L5-S1 for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure L4-L5-S1 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V (F5) and prothrombin factor II (F2) genetic 
testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that F5 and F2 genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is F2 and F5 genetic testing. This testing is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Factor V (F5) and 
prothrombin factor II (F2) genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage chair. 
 
You asked the Plan to pre-approve the chair. You say that this is a better alternative to opioids. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a massage chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump. 
 
You asked the Plan to pre-approve the services. You say that this is necessary and critical to a swollen knee 
after surgery. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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. 
 
Medicare does not consider this item to be reasonable or necessary. 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 pre-approve a fluid-circulating cold pad with pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have  debilitating foot pain, and are in need 
of orthotics prior to Fascia Release 
surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered upper limp orthosis (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro 2 represents this enrollee's best 
opportunity for regaining meaningful use for her left upper limb and has been deemed medically necessary for 
this enrollee by her provider. The Plan denied your request. The Plan says this device is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro powered upper limp orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer, Vertiflex device 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that although surgical decompression is the 
other treatment option, the enrollee does not want to have such a significant surgical procedure when an FDA 
approved, minimally invasive treatment option is available. The Plan denied your request. The Plan says this 
procedure is considered experimental and investigational as it has not been shown to be safe and effective and 
has not been shown to be helpful for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Superion interspinous spacer, Vertiflex device (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for syncope. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a very heavy-duty power wheelchair (K0839) and 
accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are under the weight range for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that a very heavy duty power wheelchair is covered 
with a patient weight capacity of 451-600 pounds. 
 
Your weight is 410 pounds. This is outside of the covered range for this wheelchair. 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 pre-approve a very heavy-duty power wheelchair (K0839) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on June 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you received a bill from the dentist and would 
like to appeal. The Plan denied your request. The Plan says you have exhausted your annual dental benefit.  
The Plan says that it paid the following already in 2021 for dental services you received: $1159.00 for date of 
Service May 27, 2021, $273.00 for date of service June 17, 2021, $556.00 for date of service June 19, 2021. 
That totals $1988.00.  The Plan paid $12 towards the dental services you received on June 23, 2021, but at that 
point, your dental benefits had been exhausted. 
 
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. Your contract explicitly states 
that you have an annual maximum of $2000 that will be paid for dental care.  You have already exhausted your 
annual benefit. 
 
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 dental 
services you received on June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the assisted living facility with home health care or in a long-term care facility on a part 
time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam (code D0150) and the dental 
x-ray complete series (code D0210) you received on November 15, 2021. 
 
You asked the Plan to pay for codes D0150 and D0210. You say that you had to switch to another dentist, so 
these services should be paid. The Plan denied your request. The Plan says you exhausted your benefits for a 
comprehensive oral exam (code D0150) and the complete series of dental x-rays (code D0210) on January 6, 
2020.  You were not entitled to have additional oral exams or complete series dental x-rays at the time of the 
services in November of 2021. 
 
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 Evidence of Coverage 
explicitly states that you are only covered for one comprehensive oral exam and one complete set of x-rays 
every three years.  This restriction applies regardless of the reason for the services. 
 
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 comprehensive dental exam (code D0150) and the dental x-ray complete series (code D0210) you received on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral - periapical 
first radiographic image (D0220), and extraction (D7210), provided on September 26, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the out of network member liability was applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral - periapical first radiographic image (D0220), and extraction (D7210), provided on September 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that SNF care is medically necessary in this 
case. The Plan denied your request. The Plan says the services required are custodial in nature, and custodial 
care is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not 
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's 
high functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of 
these services) on a "daily basis" in a SNF.  As a practical matter, this patient does not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
October 14, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing (D4342). You say that the dentist 
recommended this procedure because a deep infection was causing severe pain and bleeding. You say that you 
request reconsideration of payment for periodontal treatment so your heart condition will improve. The Plan 
denied your request. The Plan says the service is not a covered 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. 
 
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 
periodontal scaling and root planing (D4342) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiographic images (D0330), prophylaxis (D1110), and 
comprehensive oral evaluation (D0150), provided on August 18, 2021. 
 
You asked the Plan to pay for the radiographic images, prophylaxis, and comprehensive oral evaluation. You 
say that the services should be covered. The Plan denied your request. The Plan says the Plan does not cover 
radiographic images and you have exceeded the maximum frequency for the cleaning and evaluation. 
 
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 
radiographic images (D0330), prophylaxis (D1110), and comprehensive oral evaluation (D0150), provided on 
August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc injection (CPT code J7327). 
 
You asked the Plan to pre-approve the medication. You say that the requested medication will be supplied by a 
pharmacy and not by the provider's office. The Plan denied your request. The Plan says this is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Monovisc injection (CPT code J7327). Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - four 
or more teeth or tooth spaces, per quadrant (CPT code D7320 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit under 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. This service is not listed in your 2022 Dental Benefit Schedule as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty not 
in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (CPT code D7320 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia (D9215) provided on May 11, 2021. 
 
You asked the Plan to pay for the local anesthesia (D9215). You say that you submitted a letter from the dentist 
explaining why the work was necessary and the paid invoice for this dental work. The Plan denied your 
request. The Plan says the claim was partially paid but CPT code D9215 remains denied as it is not a covered 
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. 
 
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 local 
anesthesia (D9215) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four removals of an impacted tooth (D7240 x4) and 
adjunctive procedure (D9999). 
 
You asked the Plan to pay for the removals of an impacted tooth and adjunctive procedure. You say that you 
need these services provided this year because you were unable to have them done last year. You also say that 
your heart is now stable enough to complete these procedures. The Plan denied your request. The Plan says 
these services are not covered under your benefit package. 
 
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 four 
removals of an impacted tooth (D7240 x4) and adjunctive procedure (D9999).