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

 
We decided that the Plan does not have to pre-approve the surgical access to an implant body (D6011) and 
bone graft at time of implant placement (D6104 x 4). 
 
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 these services are not covered under the Plan's dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical access to an implant body (D6011) and bone graft at time of implant placement (D6104 x 4).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 3, 2022, through 
June 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded a complete set of medical records 
utilized to make their determination. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 3, 
2022, through June 6, 2022.  
 
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 pre-approve an external insulin pump and supplies (E0784, A4224, 
A4225). 
 
You asked the Plan to pre-approve the insulin pump and supplies. You say that the services should be covered 
as the enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied 
correctly as the enrollee does not meet the clinical requirements to be approved. 
 
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 insulin pump and supplies. Our 
reviewer says that Our physician reviewer found the enrollee's c-peptide is not in the insulinopenic range as it 
is >200% the upper limit of normal; hence criteria for pump coverage are not met. 
 
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 insulin pump and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an external insulin pump and supplies (E0784, A4224, A4225).
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 admission is medically necessary for the enrollee 
The Plan denied your request. The Plan says the enrollee does not meet all the requirements. The Plan says that 
the 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation Facility is medically 
necessary to treat the enrollee's debilitation medical conditions. The Plan denied your request. The Plan says 
the enrollee's condition does not meet the Medicare guidelines. The Plan says that the 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 21, 2023. 
 
You asked the Plan to pay for dental services. You say that you would like reimbursement for this. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
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 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 pay for dental services. Our reviewer says that  Our 
physician reviewer found  
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for dental services provided on January 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service November 3, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional visits of speech therapy (ST). 
 
You asked the Plan to pre-approve the ST visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not reasonable and necessary. 
 The Plan must follow Medicare rules. 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 pre-approve the ST visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are 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 ST visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional visits of speech therapy (ST).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. 
The Plan says this service 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 this procedure is considered experimental. The reviewer found that the documentation does not show a clear cause of the enrollee's pain. Therefore, the reviewer found that the 
requested Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #14 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for you to get a 
replacement crown. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because pontics are not covered by the Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6240) for tooth #14
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on October 13, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service 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 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 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 nursing facility care provided on October 13, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit provided on September 6, 
2022, and a specialist office visit provided on March 28, 2023. 
 
You asked the Plan to waive the copayments for an office visit and a specialists office visit. You say that you 
were told that you were charged incorrectly. 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 $5 
copayment for a visit with a health care professional. Your contract with the Plan clearly says that you must 
pay a $45 copayment for a specialist office visit. 
 
You have been asked to pay a $5 copayment for an office visit provided on September 6, 2023. You have also 
been asked to pay a $45 copayment for the specialist office visit provided on March 38, 2023. These 
items/services fall within the physician/practitioner services, including doctors office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the office visit provided on September 6, 2022, and a 
specialist office visit provided on March 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on April 4, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this facility is a non-Medicare approved/certified 
freestanding emergency facility. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on April 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629 x 2). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this procedure is 
experimental and therefore is not covered. 
 
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 the provided documentation does not show a clear cause of the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629 x 2).
Appeal type: Surgery
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 addresses 
vertebrogenic pain by addressing a gap in the treatment algorithym for patients suffering from chronic low 
back pain. You say that the peer-reviewed literature clearly supports your request and the science supporting 
the safety and effectiveness of the procedure is robust. The Plan denied your request. The Plan says the 
Intracept procedure is not considered to be 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 the Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found one double-blind randomized study has shown that improvement with the Intracept procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that 
the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the 
published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. In addition, the provided records in this case document moderate disc 
degeneration and facet arthropathy on spinal imaging which may be the cause of the enrollees back pain. The 
provided records in this case do not document the Intracept procedure meets Medicare criteria for safe, 
effective, reasonable, and necessary as required by the Social Security Act, Section 1862 (a)1(A) and the  
42 CFR Section 411.15(k). 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee continues to have a cognitive decline 
and requires additional services. The Plan denied your request. The Plan says the additional visits are not 
medically necessary. 
 The Plan must follow Medicare rules. 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 pre-approve the PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an eye refraction and eyeglasses provided on 
February 23, 2023. 
 
You asked the Plan to reimburse you for the eye refraction and eyeglasses. The Plan denied your request. The 
Plan says the enrollees Plan provides coverage for a routine eye exam however the enrollee must see a 
provider that is in-network with her Plan. The enrollees Plan also does not offer coverage for non-Medicare 
covered eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The 
Plan covers these services when provided by an in-network provider. 
 
We looked at the file the Plan's rules and Medicare rules. The file shows that you did not receive the eye 
refraction from an in-network provider. The file also shows that your Plan does not provide coverage for a 
routine eyewear benefit. Medicare does not pay for low vision aids. Therefore, we decided that the Plan does 
not have to reimburse you for an eye refraction and eyeglasses provided on February 23, 2023.