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

 
We decided that the Plan has to pre-approve a pontic (D6245) on tooth #19 and retainer crowns (D6740) on 
tooth #18 and #20. 
 
You asked the Plan to pre-approve the dental services. You say that the bridge is recommended to fully restore 
proper function and alignment of teeth. The Plan denied your request. The Plan says that the requested services 
are not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the dental services are medically necessary. Our physician reviewer found that a review of the 
documentation indicates that tooth #19 is the only missing tooth in the lower arch. The replacement of this 
tooth will prevent adjacent teeth from drifting and restore good bilateral masticatory function. A removable 
appliance would not be indicated for replacement of a single missing tooth.  
 
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 of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a pontic (D6245) on tooth #19 and retainer crowns (D6740) on tooth #18 and #20.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the PVA at L4 and L5. 
 
You asked the Plan to pre-approve the PVA. You say that the requested procedure is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered if all of the criteria listed in the 
Medicare rules section 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 the PVA. Our reviewer says that the 
procedure is medically necessary. Our physician reviewer found that the enrollee has had six weeks of 
conservation therapy without improvement. The nuclear medicine study shows uptake at L4 and L5. The mild 
uptake is reflective of subacute vertebral body fractures. 
 
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 PVA have been met. Therefore, we decided that the Plan has to pre-approve 
the PVA at L4 and L5.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mastegraft allograft for C3-C6 posterior cervical 
instrumentation. 
 
You asked the Plan to pre-approve Mastegraft allograft. You say that this procedure is warranted, appropriate, 
and medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Mastegraft allograft have not been established. 
 
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 Mastegraft 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 request to be an effective and/or safe treatment for the noted pathology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mastegraft allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Mastegraft allograft for C3-C6 posterior cervical instrumentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vaccination (90471, 90738) provided on December 29, 
2022. 
 
You asked the Plan to pay for the vaccination. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this claim is not eligible for payment. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Japanese 
Encephalitis vaccine. Additionally, code 90738 has a status indicator of "M" and is not billable to the fiscal 
intermediary. Therefore, we decided that the Plan does not have to pay for a vaccination (90471, 90738) 
provided on December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 11, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor ankle / foot system (L5973). 
 
You asked the Plan to pre-approve the item. You say that this feature is medically necessary. The Plan denied 
your request. The Plan says this feature is not 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 item. Our physician reviewer found 
the criteria have not been met for the requested microprocessor foot. The request exceeds the enrollee's 
functional needs per documentation. The medical documentation does not support that a mechanical K3 foot 
will not meet the enrollee's needs. 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 item have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a microprocessor ankle / foot system (L5973).
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 the LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are 
being met at the current hospital facility. 
 
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 documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility.  The enrollee has improved medically and can receive further care at the current acute care hospital or a lower 
level of care when deemed appropriate.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic items L5962 and L5986. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee requires a protective outer 
covering or a multiaxial motion. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
prosthetic items L5962 and L5986.
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. You say that you are afraid you will fall if released before your 
comfortable with walking and balance. The Plan denied your request. The Plan says your records do not show 
that you require skilled nursing or rehabilitation on a daily basis that can only be provided on an inpatient basis. 
Services required can safely be received at a different setting, at a, home with home health, in residential care, 
or home with close follow-up with your doctor. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve insertion of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an implantable cardiac monitor (ICM) in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
January 4, 2023. 
 
You asked the Plan to pay for this dental service. 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 panoramic 
radiographic image 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 panoramic radiographic image provided was exhausted on date of service April 19, 
2023. Specifically, the Plans contract states that one full mouth or panoramic radiographic image is covered 
every five years. You received a full mouth x-ray on April 19, 2023 that was paid for by the Plan. This claim 
was processed prior to the reprocessed claim for date of service January 4, 2023. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) provided on January 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 6, 2022, to May 19, 
2022. 
 You asked the Plan to pay for the home health services. You say that you believe this claim was submitted 
correctly. 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 April 3, 2022. The NOA was not received by the Plan until August 29, 
2022. 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 May 6, 2022, to May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic rhizotomy (22102). 
 
You asked the Plan to pre-approve endoscopic rhizotomy. 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 endoscopic rhizotomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found endoscopic rhizotomy is experimental for back pain with multiple levels of 
degenerative joint disease (djd). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic rhizotomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endoscopic rhizotomy (22102).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 19, 2020, to October 2, 
2020. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs.  
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from September 19, 2020, to October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 4, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease (COPD). The documentation does not contain sufficient 
detailed information in the medical record to justify the use of a ventilator. Failure of bi-level positive airway 
pressure (BiPAP) therapy is not documented. The criteria for coverage are not met and the ventilator is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.