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

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341) and the periodontal scaling and root planing-one to three teeth per quadrant (D4342) 
provided on April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 your benefit for the services provided was exhausted on date of service December 23, 2021. 
Specifically, the Plans contract states that periodontal scaling and root planing-four or more teeth per quadrant 
(D4341) and periodontal scaling and root planing-one to three teeth per quadrant (D4342) are each covered 
once every 24 months. You previously received both dental services on December 23, 2021, less than 24 
months prior, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the 
dental services provided in this case. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing-four or more teeth per quadrant (D4341) and the periodontal scaling and 
root planing-one to three teeth per quadrant (D4342) provided on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you are unable to get on your feet without 
treatment.  The Plan denied your request. The Plan says an epidural steroid 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that you have had multiple epidural 
steroid injections in the past. Also, you have been receiving treatment for the pain with epidural steroid 
injections every 2 months from January 17, 2023, to May 16, 2023, for a total of 4 treatments in less than 12 
months. The LCD criteria limits the number of injections to 4 in a 12-month period as well as requiring 50% 
pain relief that lasts 3 months. The records do not support another injection and therefore the request is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483, 64484) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve epidural steroid injections to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
epidural steroid injections (64483, 64484) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 30, 2022.  
 
You asked the Plan to pay for the physical therapy services. You say that the records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says they do not cover charges for 
treatment of TMJ other than by an open cutting operation.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary. The rules say that Medicare pays for medically necessary outpatient therapy. 
 
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 pay for the physical therapy services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not 
reveal an objective physical examination by the ordering provider confirming the diagnosis of TMJ. There is no 
interval reassessment by the provider confirming the need for skilled therapy for TMJ. The documentation 
from the ordering provider does not support the need for skilled professional therapy, nor does it support that 
the amount, frequency, and duration of the services was reasonable under accepted standards of practice.  
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. 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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested SI joint RFA 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 SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that an epidural 
steroid 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the prior epidural steroid 
injection provided minimal relief and the magnetic resonance imaging (MRI) shows an extruded disc. The 
repeat epidural steroid injection is not indicated when the prior epidural steroid injection did not provide at 
least 50% pain relief for three months. Therefore, the request is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (74230, 72040, 70100, 70310 and 
74240) provided on January 30, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. For codes 74240 and 
74230, the documentation supports the studies represented by Current Procedural Terminology (CPT) were 
performed at a nursing home (via mobile van/portable x-ray) which are denied as an excluded place of service. 
In addition, the POS 11 is not supported. Per Medicare Claims Processing Manual, "When services are 
furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. For 
example, a mobile unit may be sent to a physicians office or a skilled nursing facility. If the mobile unit is 
serving an entity for which another POS code already exists, providers should use the POS code for that entity. 
However, if the mobile unit is not serving an entity which could be described by an existing POS code, the 
providers are to use the Mobile Unit POS code 15. 
 
Codes 72040, 70100, and 70310, are denied. Place of service 11 was billed; however, documentation received 
does not support the services performed in an office or other outpatient setting but rather in a mobile setting at 
a SNF. There is a more appropriate place of service code. Per Centers for Medicare & Medicaid Services 
(CMS) Medicare Claims Processing Manual Chapter 26 10.5 (Special Considerations for Mobile Unit Settings 
(Code 15) page 32 of 77) "If the mobile unit is serving an entity for which another POS code already exists, 
providers should use the POS code for that entity. Therefore, we decided that the Plan does not have to pay for 
the medical services (74230, 72040, 70100, 70310 and 74240) provided on January 30, 2023.
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 admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for 
admission. Services needed may be provided safely in a lower level of care.  
 
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 enrollees 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the services. 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that after discussion of all treatment options, the enrollee has chosen superficial radiation therapy (RT). 
Daily ultra-sonographic imaging prior to the administration of superficial RT was requested. Daily IGRT is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
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 would benefit from intense rehabilitation 
to address limitations.  The Plan denied your request. The Plan says based on the available information, 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, there is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 3, 2021, to 
April 13, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 521. 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 pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not indicate that the treatment ordered by the treating medical providers supported 
a diagnosis code of I50.33 (acute on chronic diastolic (congestive) heart failure. In this case, the documentation 
does not consistently and completely support the assigned secondary diagnosis code. The decision to remove 
the secondary diagnosis code and adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from April 3, 2021, to April 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380).  
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says this request does not meet the Part B step therapy criteria for Entyvio.   
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 the drug. Our physician reviewer found 
the Plan requires a trial of Stelara before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation provided indicating that the Plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric wheelchair. 
 
You asked the Plan to pre-approve an electric wheelchair. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an electric wheelchair have been met. Specifically, medical records were requested but no received. Medical necessity cannot be established without 
this documentation. Therefore, we decided that the Plan does not have to pre-approve an electric wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 16, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that the records provided support that the 
services in dispute were medically necessary.  The Plan denied your request. The Plan says they do not cover 
charges for treatment of TMJ other than by an open cutting procedure.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary. The rules say that Medicare pays for medically necessary outpatient therapy. 
 
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 pay for the physical therapy services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not 
reveal an objective physical examination by the ordering provider that supports that the enrollee has TMJ and 
requires skilled therapy for this diagnosis. The documentation does not reveal that the ordering provider clearly 
determined whether the TMJ treatment was requested to treat a dental condition/symptom or another part of the 
anatomy. It is not clear that the services were reasonable and necessary for the diagnosis and/or treatment of a 
medical illness or injury. The documentation does not reveal an interval evaluation of the enrollee supporting 
the need for ongoing skilled therapy. The documentation is not clear why the enrollee is not versed in a home 
exercise program. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on December 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on May 9, 2023. 
 
You asked the Plan to pay for the cystourethroscopy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in 
cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a cystourethroscopy provided on May 9, 2023.