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

 
We decided that the Plan does not have to pre-approve the prefabricated abutments (D6056) and the implant 
support to crown (D6057) for tooth #11 and #12. 
 
You asked the Plan to pre-approve the dental services. You say that the 2 screws are already made for the next 
2 implants and the extra crowns you need to finish the job. The Plan denied your request. The Plan says your 
benefit for the requested items or services has already 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved the prefabricated abutments (D6056) and the implant support to crown (D6057) 
for tooth #5 and #6 on January 21, 2023; therefore, your benefit for the requested items or services was 
exhausted on the date of approval of January 21, 2023. Therefore, we decided that the Plan does not have to 
pre-approve the prefabricated abutments (D6056) and the implant support to crown (D6057) for tooth #11 and 
#12.
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 the custom orthosis is medically necessary to 
help the enrollee maintain proper position for their foot. 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 the enrollee does not suffer from diabetic foot disease, and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for the enrollees condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on March 10, 2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that the provider did 
not advise you of a cost share for the services. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services 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. The total you owe is a $125 copayment for PT services ($25 copayment per 
visit x 5 visits = $125). Therefore, we decided that the Plan does not have to waive the copayment for each 
physical therapy (PT) visit provided on March 10, 2023, to March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says  the enrollee does not meet all the requirements for 
admission to an IRF. 
 
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 the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical or thoracic facet injection. 
 You asked the Plan to pre-approve injection. You say that you would be getting three injections and that the 
first injection was just a test which did not include a high dosage of medicine. The Plan denied your request. 
The Plan says a cervical or thoracic facet injection 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 injection. Our reviewer says that that 
you do not meet the LCD coverage criteria. Our physician reviewer found that you have evidence of 
radiculopathy. Therefore, the review has determined that the requested 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cervical or thoracic facet injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-intravenous conscious sedation (D9248) provided on 
February 7, 2023. 
 
You asked the Plan to pay for non-intravenous conscious sedation (D9248). You say that sedation is necessary 
for the removal of a wisdom tooth. The Plan denied your request. The Plan says according to you EOC, there is 
no coverage for this 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for non-
intravenous conscious sedation (D9248) provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on March 9, 2023. 
 
You asked the Plan to pay for core buildup (D2950). You say that the insurance description says crown 
procedures are 100% covered without exceptions. The Plan denied your request. The Plan says there is no 
coverage for core buildup (D2950). 
 
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 core 
buildup (D2950) provided on March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10006 billed for date of service January 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the service requires a qualifying service. 
 
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, we have confirmed that code the billed services is an add-on code and has not been billed with an 
appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 10006 billed for date of service 
January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of 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.  
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
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 requires a higher level of care to meet 
current medical needs. The Plan denied your request. The Plan says the IRF services you 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 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 
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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bronchoscopy (31647, 31651) and associated inpatient admission. 
 
You asked the Plan to pre-approve bronchoscopy and associated inpatient admission. You say that this is 
medically necessary. The Plan denied your request. The Plan says that the records do not show the results of a 
recent blood gas or six-minute walk test and do not show evidence that the enrollee has successfully completed 
a pulmonary rehabilitation program. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 bronchoscopy and associated inpatient 
admission. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found with severe chronic obstructive pulmonary disease 
(COPD) and emphysema, particular as this enrollee exhibits the placement of Zephyr valve via bronchoscopy 
is an endoscopic method of lung volume reduction which can have physiologic benefit similar to surgical 
interventions without the associated morbidity. Improved quality of life, activities of daily living, and 
longevity. Therefore, it is indicated per documentation and therapeutically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopy and associated inpatient admission have been met. Therefore, we 
decided that the Plan has to pre-approve bronchoscopy (31647, 31651) and associated inpatient admission.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing of autonomic nervous system function (procedure 
code 95923) rendered on August 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that based on the medical records 
provided there is no documentation that CPT code 95923 was rendered in this case. Provided records in this 
case document electromyography and nerve conduction studies were performed on 08/30/2022 but records do not document testing of autonomic nervous system function; sudomotor, including 1 or more of the following: 
quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and 
changes in sympathetic skin potential. 
 
We looked at this coder's review, the file, and Medicare rules. 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 testing of autonomic nervous system function (procedure code 95923) rendered on August 30, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 30, 2022, 
to October 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you had a system issue beyond 
your control. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 30, 2022, to 
October 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 27, 2022, to 
July 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your software vendor had a 
system issue beyond your control. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 27, 2022, to July 
26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code is listed as payable. The Plan 
denied your request. The Plan says the diagnosis codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 The file shows that CPT code 99285 was billed with diagnosis codes R26.2 and R29.6. Diagnosis code R26.2 
has an Excludes1 note that includes diagnosis code R29.6. We find that the code excluded, R29.6, should never 
be used at the same time as diagnosis code R26.2. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99285 billed for date of service January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 21, 
2022, to April 12, 2022. 
 
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 itemized bill charges exceed the UB-04 charges. 
 
The Plan must follow Medicare rules. The rules say that FL 47 on the on the UB-04/CMS-1450 form is the 
space in which the provider sums the total charges for the billing period for each revenue code 
 
We looked at the file and Medicare rules. The file shows that the itemized bill charges do not match the charges 
billed on the UB-04 claim. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services rendered from February 21, 2022, to April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diaphragm plication. 
 
You asked the Plan to pre-approve a diaphragm plication. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a diaphragm plication. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided does not indicate the presence of severe symptoms or the failure 
of conservative treatment. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a diaphragm plication have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a diaphragm plication.