Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the left total hip replacement (27130). 
 
You asked the Plan to pre-approve the left total hip replacement. You say that the service is not medically 
necessary. The Plan denied your request. The Plan says that the service is 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 left total hip replacement. Our 
reviewer says that the requested service is considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation demonstrates subjective and objective deficits that are 
corroborated by imaging studies. Also, trial and failure of conservative treatment modalities have been 
documented. 
 
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 left total hip replacement have been met. Therefore, we decided that the 
Plan has to pre-approve the left total hip replacement (27130).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) 
provided on December 27, 2022. 
 
You asked the Plan to pay for dental services. You say that both x-rays should be covered. The Plan denied 
your request. The Plan says this service is not covered under your Plan. 
 
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. Intraoral - periapical first 
radiographic image (D0220) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0220 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral - 
periapical first radiographic image (D0220) provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal 
(D6750) (tooth 7,6), pontic - porcelain fused to high noble metal (D6240) (tooth 8,10,11), pontic - 
porcelain/ceramic (D6245) (tooth 6,7,9,12). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted. Therefore, we decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal (D6750) (tooth 7,6), pontic - 
porcelain fused to high noble metal (D6240) (tooth 8,10,11), pontic - porcelain/ceramic (D6245) (tooth 
6,7,9,12).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the literature indicates that the Intracept procedure targets the basivertebral 
nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system 
unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of the Intracept device to established surgical decompression are needed.  
Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an 
alternative to standard surgical treatment. In this case, the review has determined that the requested Intracept 
procedure is not medically reasonable or necessary 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 Intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 26, 2022 to 
February 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you are appealing this denial. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 26, 2022 to 
February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient rehabilitation stay provided 
from December 13, 2022, to December 21, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient rehabilitation stay. You say that you were told 
there was a single copayment for this service. 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 $350 
copayment per day for days 1-5 each inpatient acute rehabilitation stay. Your contract with the Plan also clearly 
says you must then pay a $0 copayment for days 6-90. You have been asked to pay a $350 copayment per day for the inpatient rehabilitation services. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged past day five 
and have not been charged for the day you were discharged. You have been asked to pay a total of $1,750 
($350 copayment per day x 5 days = $1,750). 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 reduce the copayment for the 
inpatient rehabilitation stay provided from December 13, 2022, to December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve iTind system (53899). 
 
You asked the Plan to pre-approve iTind system. 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 iTind system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of a temporarily implanted nitinol device (e.g., iTind) is considered investigational as a 
treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). Further studies are 
needed to evaluate the durability of iTIND outcomes over a longer follow-up, to better define the indications of 
this approach, and to demonstrate the advantages of second-generation device over the first device. The iTind 
is not recommended in the most recent AUA Guidelines regarding treatment of BPH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of iTind system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve iTind system (53899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum limit 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 requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service November 2, 
2022. 
 You asked the Plan to pay for procedure code 93313. You say that this service was billed separately and is 
supported in the medical record. The Plan denied your request. The Plan says the payment for code 93313 is 
included in the payment for code 00540. Although code 93313 was billed with a modifier, the records do not 
support that this modifier was used correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93313 
is a column II code to column I code 00540; however, 93313 was billed with a modifier.  
 
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 procedure code 93313. Our reviewer says that this service is 
not supported for unbundled payment. Our reviewer found that the procedure report does not support modifier 
59 for a distinct procedural service, as the documentation does not include documentation to support whether 
the study is for diagnostic or monitoring purposes. When a transesophageal echocardiogram is performed by an 
anesthesiologist for intraoperative monitoring purposes only, the probe placement may not be billed separately 
as CPT coding conventions do not allow an option for the placement to be separately billed from the total 
intraoperative monitoring service. It is important that the anesthesiologist clearly document in the record 
whether the study is for diagnostic or monitoring purposes. Without this documentation, there is insufficient 
support for the use of the 59 modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93313 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93313 billed for date of service November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 27, 2022 to 
July 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you are appealing this denial. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 27, 2022 to July 26, 
2022.
Appeal type: 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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee would benefit from physical and occupational therapy, the enrollees rehabilitation needs can be safely 
provided in an alternate and low intensity setting such as in a skilled nursing facility or long-term care with 
therapy. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroplasty surgery. 
 
You asked the Plan to pre-approve sacroplasty. You say that you need this to not continue living in pain. The 
Plan denied your request. The Plan says that this 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 sacroplasty. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the current published large-scale, long-term, peer-reviewed literature supports sacroplasty for 
the treatment of sacral insufficiency fractures. The procedure is not favored over conservative measures. The 
documentation demonstrates subjective and objective deficits that are supported by imaging studies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroplasty have been met. Therefore, we decided that the Plan has to pre-
approve sacroplasty surgery.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve stimulation unit provided on December 22, 2022, by 
an OON provider. 
 
You asked the Plan to pay for the nerve stimulation unit. You say that this item was medically necessary. The 
Plan denied your request. The Plan says that this item was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the enrollee may choose to use the Plan's Point-of-Service benefit to see an out-of-network provider for most covered services. Out-of-network providers must be Medicare certified and prior 
authorization rules still apply. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nerve stimulation unit provided on December 22, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve mandibular partial denture (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on July 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the chiropractic care. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says services rendered out-of-network are not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic care provided on July 29, 2022, by 
an out-of-network (OON) provider.
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 you are requesting an expedited reconsideration 
stating the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can be 
provided in a lower intensity and alternate setting such as in-home with continued therapies. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 26 routine transportation trips. 
 
You asked the Plan to pre-approve an additional 26 routine transportation trips. You say that you need to get to 
your medical appointments. The Plan denied your request. The Plan says this request will exceed the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 26 routine transportation trips.