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

 
We decided that the Plan does not have to pay for a gingival flap procedure, bone replacement graft, biologic 
materials to aid in soft and osseous tissue regeneration, guided tissue regeneration (D4265, D4267, D4241, 
D4263) provided on February 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 gingival 
flap procedure, bone replacement graft, biologic materials to aid in soft and osseous tissue regeneration, guided 
tissue regeneration (D4265, D4267, D4241, D4263) provided on February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrophysiologic study and catheter ablation for 
premature ventricular contractions (PVC's) (93654, 93623, 93609, 93620). 
 
You asked the Plan to pre-approve an electrophysiologic study and ablation. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says there is no clinical evidence 
that the enrollee meets medical necessity criteria for the requested service. 
 
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 an electrophysiologic study and 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the PVC burden is under 8%. There is no evidence of 
syncope or any significant supraventricular or ventricular arrhythmias. In summary, there is insufficient 
documentation to support the medical necessity for electrophysiologic study with catheter ablation of PVCs in 
this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrophysiologic study and ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electrophysiologic study and catheter ablation for 
premature ventricular contractions (PVC's) (93654, 93623, 93609, 93620).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be able to do more for herself 
upon release which therapy could help. Services needed may be provided safely in a lower level of care. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements. 
 
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. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TTE (93306) provided on February 22, 2023. 
 
You asked the Plan to pay for echocardiography, transthoracic. You say that the medical records submitted 
supports CPT code 93306 and should be paid. The Plan denied your request. The Plan says the submitted 
medical records do not indicate that echocardiography, transthoracic (TTE) (93306), real-time with image 
documentation (2D), includes M-mode recording was performed. The Plan says that the documentation does 
not contain all elements for a complete echocardiogram; therefore, the CPT code 93306 cannot be verified.  
 
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 93306 is Echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for TTE w/doppler complete (93306) was provided on February 
22, 2023. Our reviewer says that the documentation does not contain all elements for a complete 
echocardiogram. Therefore, the billed CPT code cannot be verified. Our reviewer found the documentation 
submitted does not meet criteria. The procedure report does not include sufficient documentation to confirm a 
complete echocardiogram was performed. A completed TTE (93306), requires real-time imaging and 
documentation of 2D and M-mode images of the bilateral atria and ventricles; spectral and color doppler over 
the aortic, mitral, tricuspid, pulmonic valves; and evaluation of the pericardium and adjacent portions of the 
aorta.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE w/doppler complete (93306) was provided on February 22, 2023, have not 
been met. Therefore, we decided that the Plan does not have to pay for echocardiography, transthoracic (TTE), 
real-time with image documentation (2D), includes M-mode recording, when performed, complete, with 
spectral doppler echocardiography, and with color flow doppler echocardiography (93306) provided on 
February 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you had a change in your condition and a decrease 
in mobility. The Plan denied your request. The Plan says a SNF admission is not medically necessary.   
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You enrollee do not 
require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Venofer 
carries an off-label, medically accepted indication for iron deficiency anemia. A search of the Food and Drug 
Administration Drug Shortages database shows no shortage of Infed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on January 20, 2023. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you were unaware that you had to go 
through a Plan network provider. The Plan denied your request. The Plan says hearing aids purchased outside 
of the Plan hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through an in-network Plan hearing vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5298) provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on April 14, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 . 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $300 toward your 
purchase of frames (with standard lenses covered in full). The Plan rules also says that options that are not 
covered include (but are not limited to) antireflective coating. Based on this information, we decided that the 
Plan's rules for coverage of anti-reflective coating (V2750) have not been met. Therefore, we decided that the 
Plan does not have to pay for anti-reflective coating (V2750) provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you were set up for dentures and they 
were almost finished because the dentist thought they would be covered however the claim was denied. You 
also say that you have no teeth and will not use any other dental services. The Plan denied your request. The 
Plan says these services are no covered 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 Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
denture - maxillary (D5110), and complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options, patient weight capacity up to and including 300 pounds (K0861) and power seat elevation 
system (E2300).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you would like the 
documentation provided for the wheelchair and accessories that are medically necessary to meet the enrollee's 
current needs to be reconsidered. The Plan denied your request. The Plan says based on Medicare guidelines 
and the information provided about the enrollee's condition, they 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.  
 
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 durable medical equipment (DME). 
Our reviewer says that the enrollee does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power 
options, patient weight capacity up to and including 300 pounds (K0861) and power seat elevation system 
(E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (EBT) and radiation (0394T, 
77280, 77290, 99213). 
 
You asked the Plan to pre-approve electronic brachytherapy and radiation. You say that you disagree with the 
denial. The Plan denied your request. The Plan says unproven treatments cannot be covered except in special 
circumstances. EB is considered unproven for your condition. 
 
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 electronic brachytherapy and radiation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found electronic brachytherapy (EBT) devices, which are similar in that they 
deliver low energy radiation, are marketed by other manufacturers (and are Food and Drug Administration (FDA) approved). EBT is somewhat different in that energies up to 50 kilovolts (kV) are generated electrically 
via an electronic brachytherapy source. The most recent National Comprehensive Cancer Network (NCCN) 
guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient long-term 
efficacy and safety data to support routine use of electronic surface brachytherapy. Earlier versions did not 
specifically address EBT or superficial radiation (SRT), and only mentioned electron and orthovoltage beams 
as means to deliver radiation. Generally, electron therapy or orthovoltage therapy are considered standard 
means to deliver radiation. EBT is currently subject only to medical device review by the FDA, which 
considers safety and effectiveness of the device based on a standard that does not assess efficacy, outcomes, or 
potential clinical applications. There are no compelling reasons offered for why SRT would be needed over 
more standard approaches of radiation delivery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy and radiation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve electronic brachytherapy (EBT) and radiation (0394T, 
77280, 77290, 99213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that genicular nerve blocks have been 
the only procedural treatments that have provided benefit. The Plan denied your request. The Plan says the 
genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer that the genicular nerve 
block is considered experimental therapy and is the subject of ongoing clinical trials. 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
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 you want to be admitted to an acute rehabilitation 
facility because you were active and independent prior to being admitted to the hospital. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary.  
 
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 you are medically stable and do not need physician supervision 3 times a week 
or intensive therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you 
may benefit from physical and occupational therapy your needs can be provided in an alternate setting such as 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0442. We decided that the Plan does not have to pay for 93000.  
 You asked the Plan to pay for procedure codes 93000 and G0442 rendered on February 28, 2023.. You say that 
this should be paid for. The Plan says that the codes were not documented in the notes. 
 
We decided that the Plan has to pay for G0442.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The narrative of the received case file indicates a denial for G0492, but a review of the billing 
documentation does not show that this code was billed on this date of service. Other than CPT 93000, the only 
other denied code for this date of service was G0442. The plan has not forwarded any denial reason for this 
code. The records do show that G0442 - which represents annual alcohol misuse screening, 15 minutes - was 
performed on this date of service, with education on the effects of alcohol. 
 
We looked at the file and Medicare rules. The plan has not provided any denial reason for G0442. Based on 
this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for G0442.  
 
We also decided that the Plan does not have to pay for 93000. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of procedure code 93000 is 
"Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report." 
 
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 for CPT 93000. Our reviewer says that the medical 
record includes an EKG performed, which documents "unconfirmed report." The definition of the code requires 
interpretation and report. Therefore, CPT 93000 cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93000 have not been met. Therefore, we decided that the Plan does not have to 
pay for 93000. 
 
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.