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

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy, premolar 
tooth (excluding final restoration) (D3320) for tooth number 20. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says your benefit for the core buildup (D2950) has already been 
exhausted. The Plan also says that no x-rays were submitted for endodontic therapy, premolar tooth (excluding 
final restoration) (D3320) for tooth number 20. 
 
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 your benefit for core buildup (D2950) was exhausted on date of service February 1, 2021.  
 
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 endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) for tooth number 20. Our reviewer says that the requested dental services 
are not medically reasonable and necessary. Our physician reviewer found the supplied x-ray is not diagnostic 
for an endodontic lesion, and no dental records were supplied describing symptoms that would indicate and 
endodontic problem. Our physician reviewer also found that no clinical records were supplied that would 
indicate any pulp testing was performed. Our physician reviewer also found that the criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage endodontic therapy, premolar tooth (excluding final restoration) (D3320) for tooth 
number 20 have not been met. 
 
Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic 
therapy, premolar tooth (excluding final restoration) (D3320) for tooth number 20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95937-26 billed for date of service December 29, 2022. 
 
You asked the Plan to pay for code 95937-26. You say that this service was medically necessary and is 
supported by the medical records. The Plan denied your request. The Plan says code 95937-26 is not supported. 
The medical records indicate that train of four testing was performed. It is inappropriate to bill code 95937 for 
train of four testing. 
 
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 95937-26 is Neuromuscular junction test. 
 
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 code 95937-26. Our reviewer says that code 95937-26 is not 
supported by the medical record. Our reviewer found the record states that this code was reported for train of four testing performed during intraoperative neuromonitoring. According to CPT rules, train of four testing is 
included in intraoperative neuromonitoring and cannot be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95937-26 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95937-26 billed for date of service December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration based 
on medical necessity. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to be unstable and would be inappropriate for transfer at this 
time. There are no services at the LTACH that the enrollee requires that are not already available and covered 
at the current facility. Transfer to the LTACH would not be clinically advantageous and completion of 
treatment at the current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS. 
 
You asked the Plan to pre-approve a TENS. You say that the medicines for pain management were not helping 
and can be addicting and can cause high blood pressure and stomach upset. The Plan denied your request. The 
Plan says the requested TENS unit does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a TENS is covered when the criteria listed in the 
Medicare rules section of this decision are met. 
 
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 TENS. Our reviewer says that the 
requested TENS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Medicare NCD specifically excludes coverage of TENS for low back pain unless the patient is 
part of a CMS approved clinical trial. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TENS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a TENS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology care with a tertiary level of care provider. 
 You asked the Plan to pre-approve urology care. You say that you have been seeing this doctor since 2012 and 
have received multiple treatments. The Plan denied your request. The Plan says you do not need to be treated at 
the tertiary level of care and can be treated by another urologist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs.  
 
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 urology care. Our reviewer says that 
you do not meet criteria for urology care with a tertiary level of care provider. Our physician reviewer found 
the Plan is offering adequate care to meet your needs through its referral to a community-level urology 
specialist. There is nothing unique about your condition that would make it medically necessary for you to see 
a tertiary level of care provider. The Plan has community-level providers who meet the standards of care 
required for treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urology care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve urology care with a tertiary level of care provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 27, 2023, to 
April 6, 2023. 
 You asked the Plan to pay for the home health services. You say that these are covered services. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 15, 2022. The NOA was not received by the Plan until April 17, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 27, 2023, to April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation showing any pressure ulcers that necessitate the use of this 
mattress. 
 
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 mattress. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has intact skin. The enrollee does not have multiple stage II, or stage III or IV wounds 
and has not received a flap for skin repair. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure reducing air mattress.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy and spinal fusion at the L5-S1 
level (22614, 63048, 22853, 22585). 
 
You asked the Plan to pre-approve lumbar laminectomy and spinal fusion at the L5-S1 level. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 lumbar laminectomy and spinal fusion 
at the L5-S1 level. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found no compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested lumbar laminectomy and spinal fusion at the L5-S1 level is not medically reasonable or 
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 lumbar laminectomy and spinal fusion at the L5-S1 level have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar laminectomy and spinal fusion at the 
L5-S1 level (22614, 63048, 22853, 22585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64450) provided on March 24, 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 64450 is "Injection(s), anesthetic agent(s) and/or steroid; 
other peripheral nerve or branch". 
 
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 64450 is 
not supported by the records provided. Our reviewer found that the record states that the procedure performed 
was an IPACK block. This is not considered a nerve block and should be reported with unlisted code 64999.  
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 (64450) provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you are requesting reconsideration for 
the requested test strips. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite 
test strips.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says an admission to an IRF is not reasonable and 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD criteria requires "no non-facet pathology that could explain the source of the 
patient's pain."  Clearly, this enrollee has multiple pain generators and therefore, the request is deemed not 
medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 really need this equipment. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 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 you do not currently meet criteria for a home ventilator with the documentation and data provided. Our 
physician reviewer found you have very severe COPD and subsequent chronic respiratory failure. Our reviewer 
also found that you have not trialed or failed BIPAP therapy and hence should attempt prior to escalation to 
home ventilator. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that the test was medically necessary. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L3485-RT billed for date of service March 
16, 2023. 
 
You asked the Plan to pay for the billed service. You say that supporting documentation was submitted. The 
Plan denied your request. The Plan says the required modifier was not 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 find that CPT code L3485-RT is not supported. The item billed without a KX modifier will be denied as 
noncovered because coverage is statutorily excluded. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code L3485-RT billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you are seeing a podiatrist and were advised to stay 
off of your feet. You also say you have a wheelchair, but are no longer 300 pounds, and it is too large for you 
to get around your house. The Plan denied your request. The Plan says you do not meet the guidelines based on 
the records reviewed. 
 
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 a scooter. Our reviewer says that the 
criteria have not been met for a scooter (K0800). Our physician reviewer found you have a personal mobility 
deficit that impairs participation in MRADLs. The documentation states that you have chronic shoulder and 
wrist pain, but the documentation does not reveal a detailed examination of the upper extremities supporting 
limitations such and range of motion and strength that would prevent use of a manual wheelchair or walker. 
Our reviewer also found that you may have the cognitive function and ability to use the scooter, but the 
documentation does not show an objective home evaluation with objective measurements and evidence of 
adequate access between rooms and in and out of the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter (K0800).