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

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #18 provided on December 
19, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you are dissatisfied about the benefit 
limitations. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 paid $203 for dental services on July 12, 2022. On October 13, 2022, the Plan paid $1,435 for 
dental services. On December 19, 2022, the Plan paid $362 for dental services. For the year of 2022 the Plan 
paid $2,000 ($203 paid + $1,435 paid + $362 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2022 was exhausted on the date of service of December 19, 2022. Therefore, we decided 
that the Plan does not have to pay more for a crown (D2740) for tooth #18 provided on December 19, 2022.
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. The Plan denied your request. The Plan says you do not meet the 
Medicare rules for coverage of SNF care. 
 
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 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 do not require 
daily skilled nursing and/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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (22899) provided on January 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 22899 is "Unlisted procedure, spine". 
 
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 use of code 22899 is 
not supported by the records provided. Our reviewer found that the operative report documents "Anterior 
retroperitoneal exploration and exposure of lumbar spine, L4-L5, with extensive mobilization and dissection of 
major retroperitoneal vascular structures and organs with increased difficulty due to morbid obesity (CPT code 22899-59)". In this case, the operative report does not include sufficient documentation to confirm an unlisted 
procedure. The procedure report describes a lumbar fusion with cage insertions and instrumentation, which has 
an assigned CPT code. 
 
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 the services (22899) provided on January 4, 2023.
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. The Plan denied your request. The Plan says this request 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 the complexity of the enrollee's medical, rehabilitation, and nursing needs (combined 
complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to 
rehabilitative care. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in an SNF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 3, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM require 
insulin use or low blood sugars. This enrollee is not using insulin and is not having low blood sugars that we 
are told of. The enrollee is not on a medication that causes low blood sugars typically. We are also not told why 
the fingerstick meter is not sufficient for the enrollee needs. Although a CGM may help the enrollee, the 
coverage criteria are not met at this time for a CGM. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 80061, 82306, 82607, 83540, 84443 
and 82248 billed for date of service January 23, 2023. 
 
You asked the Plan to pay for procedure codes 80053, 80061, 82306, 82607, 83540, 84443 and 82248. You say 
that you are an independent laboratory, and these services were ordered by the enrollee's physician. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. For code 82248 (bilirubin testing), there is no evidence that this test was requested or intended by the 
provider. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. The rules 
also say that services which are not medically necessary are not covered. Laboratory services are typically 
requested on an order form. While a physician order is not required to be signed, the physician must clearly 
document, in the medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The file includes evidence that codes 80053, 80061, 82306, 82607, 
83540 and 84443 were reimbursed by the Plan on April 10, 2023. Comparison of the two claims shows these 
are exact duplicates. There is no evidence presented to support that the billed items/services were provided 
twice on the same date. Based on this information, we decided that the Medicare rules for procedure codes 
80053, 80061, 82306, 82607, 83540 and 84443 have not been met.  
 
In addition, code 82248 (bilirubin, direct testing) was reported on this claim; however, the physician order 
provided does not support that this test was requested. A comprehensive metabolic panel is defined as Albumin 
(82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide (bicarbonate) (82374), Chloride 
(82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total 
(84155), Sodium (84295), Transferase, alanine amino (ALT), (SGPT) (84460), Transferase, aspartate amino 
(AST), (SGOT) (84450) and Urea nitrogen (BUN) (84520). A lipid panel is defined Cholesterol, serum, total 
(82465), Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), Triglycerides 
(84478), Thyroid stimulating hormone (TSH), Iron, Cyanocobalamin (Vitamin B12), Vitamin D; and 25 
hydroxy. Based on this information, we decided that Medicare rules for procedure code 82248 are not met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 80053, 80061, 82306, 82607, 
83540, 84443 and 82248 billed for date of service January 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulatory continuous glucose monitoring 
provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for ambulatory continuous glucose monitoring. You say that you 
feel that the bill you got from the provider is a charge for absolutely nothing. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for ambulatory continuous glucose monitoring. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ambulatory continuous glucose monitoring provided on 
April 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel allograft (20930). 
 
You asked the Plan to pre-approve Nuvasive Osteocel allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the Nuvasive Osteocel Allograft 
in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 Nuvasive Osteocel allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nuvasive Osteocel allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Nuvasive Osteocel allograft (20930).
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 safely discharged home and require 
IRF services to return your independence. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve esophagogastroduodenoscopy (EGD) with biopsy (43239), upper 
gastrointestinal endoscopy (43235), EGD intramural ultrasound (US) needle aspirate/biopsy esophagus 
(43238), and EGD US exam surgical altered stomach duodenum/jejunum (43259). 
 
You asked the Plan to pre-approve the EGD. You say that this service is medically necessary for the enrollee as 
shown in the medical records. The Plan denied your request. The Plan says that this service is not medically 
necessary. 
 
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 the EGD. Our reviewer says that the 
requested EGD is considered medically reasonable and necessary in this case. Our physician reviewer found, 
though limited, the gastroenterology note in the history of present illness (HPI) sections notes epigastric pain. 
This persisted despite the proton-pump inhibitors (PPI) on the enrollee's medication record. The reviewer found 
that given the enrollee's age, the EGD is medically reasonable and necessary. The EGD with ultrasound was for 
the pancreatic lesion that was also completed but not questioned. 
 
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 EGD have been met. Therefore, we decided that the Plan has to pre-approve 
esophagogastroduodenoscopy (EGD) with biopsy (43239), upper gastrointestinal endoscopy (43235), EGD 
intramural ultrasound (US) needle aspirate/biopsy esophagus (43238), and EGD US exam surgical altered 
stomach duodenum/jejunum (43259).  
 
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: 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 you feel the enrollee meets Medicare criteria and 
will benefit from an IRF admission. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services requested 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 enrollee has limited rehabilitation goals as they are dependent on a power 
wheelchair and has very limited endurance. The enrollee cannot participate in nor do they require intensive 
therapy and frequent physiatry oversight to recover from a deconditioned state following an acute illness. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration and have 
submitted medical records for review. The Plan denied your request. The Plan says the request for a ventilator 
is not medically necessary because the documentation does not support that this device meets but does not 
exceed the enrollee's need. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has documentation to 
support COPD, but it is unclear whether chronic respiratory failure is present. Documentation does not support 
the medical necessity or rational for a ventilator. The ordered setting will be used as BIPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a periodic oral evaluation (D0120), bitewings (D0274), and a 
cleaning (D1110). 
 
You asked the Plan to pre-approve the dental services.. You say that you are requesting dental services not 
medical services. The Plan denied your request. The Plan says that the requested dental services are not eligible 
for coverage under the medical benefit. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the requested dental services are covered under the enrollee's EOC, 
and the Plan has not demonstrated that the $2,000 dental benefit maximum has been exhausted. Therefore, we 
decided that the Plan has to pre-approve a periodic oral evaluation (D0120), bitewings (D0274), and a cleaning 
(D1110).  
 
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.