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

 
We decided that the Plan does not have to pre-approve Synthes Fibergraft allograft (20930). 
 
You asked the Plan to pre-approve Synthes Fibergraft allograft. 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 Synthes Fibergraft 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 no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Synthes 
Fibergraft allograft 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 Synthes Fibergraft allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synthes Fibergraft allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from July 28, 2022, 
and August 2, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this plan is 
secondary to the enrollee's primary insurance plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the billed services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the physical therapy services provided from July 28, 2022, and August 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mandibular partial denture - cast metal framework 
with resin denture bases (D5214) provided on May 9, 2022. We also decided that the Plan does not have to pay 
for the intraoral - periapical first radiographic image provided on May 9, 2022. 
 
You asked the Plan to pay more for the mandibular partial denture. You also asked the Plan to pay for the 
intraoral - periapical first radiographic image. You say that you were trying to establish all your medical/dental 
needs while planning your wedding out-of-state. You also say that you were told this provider was in-network 
and now you have been informed they will not be in-network till the summer of 2023. The Plan denied your 
request. The Plan says your benefit for the mandibular partial denture $2,000 dollar limit was partially met. The 
Plan also says that your benefit for the intraoral - periapical first radiographic image 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Specifically, 
coverage for intraoral radiographic imaging is limited to one procedure code per calendar year. The records 
show that the Plan paid for an intraoral radiographic image for date of service December 8, 2022. This 
exhausted the benefit for intraoral radiographic imaging provided in the 2022 calendar year. Therefore, the Plan 
does not have to pay for the intraoral - periapical first radiographic image provided on May 9, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Specifically, 
the benefit for supplemental dental coverage is limited to $2,000 annually. The records show that the Plan paid 
$1,632 under claim number ending in 52939 for dental services provided on January 14, 2022. The records 
show that the Plan paid $127 under claim number ending in 30344 for dental services provided on May 9, 
2022. The records show that the Plan paid $241 under claim ending in 24551 for dental services provided on 
December 8, 2022. This means that the Plan paid $2,000 in total for dental services provided in 2022. This 
exhausted the annual dental benefit allowance for the 2022 calendar year. Therefore, the Plan does not have to 
pay more for the mandibular partial denture - case metal framework with resin denture bases (D5214) provided 
on May 9, 2022. 
 
Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture - cast metal 
framework with resin denture bases (D5214) provided on May 9, 2022. We also decided that the Plan does not 
have to pay for the intraoral - periapical first radiographic image. provided on May 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 22, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 22, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
22, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 22, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 22, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 22, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 22, 
2023, forward.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found The Plan erred in its denial of IRF admission. 
 
Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall complies with 
the various documentation requirements for IRF admission (e.g., as best summarized by physical therapy (PT) 
note from October 21, 2023 and note from October 23, 2023). Indeed, this beneficiary's 
condition is in fact complex and fragile, and the enrollee's multi-factorial pain complaints merit close physician 
titration of the enrollee's medications. With such management, there is every reason to expect that the pain can 
be controlled enough for the enrollee to participate in and benefit from IRF-level services to include at 
minimum PT, occupational therapy (OT), physician oversight of overall polypharmacy, and case manager 
coordination of any additional services that might be needed to make a sustainable return home, as well as 
avoid preventable readmissions to the acute hospital. It is highly unlikely that skilled nursing facility (SNF) 
level care could get the enrollee through any appreciable amount of therapy. 
 
Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pre-approve the interim crowns - further treatment or completion of 
diagnosis necessary prior to final impression (D2799), and occlusion analysis - mounted case D9950). 
 
You asked the Plan to pre-approve the interim crowns and occlusion analysis. The Plan denied your request. 
The Plan says these services are not covered in your dental benefit. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the interim 
crowns - further treatment or completion of diagnosis necessary prior to final impression (D2799), and 
occlusion analysis - mounted case D9950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you say that you disagree with the denial for the admission to a LTACH. The Plan denied your request. The Plan says the enrollee is receiving the care they need in the facility they are currently are at.

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 you are receiving the appropriate care in the current acute care setting. Documentation does not support that LTACH services are medically appropriate at this time.

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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
December 1, 2023 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
copayments. 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 $225 
copayment for each inpatient hospital care.  
 
You have been asked to pay a $225 copayment for the inpatient hospital stay provided on December 1, 2022. 
This item/service falls within the inpatient hospital care 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 copayment for the inpatient hospital stay provided on December 1, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided by a chiropractor on June 
16, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that based on your chiropractic benefit this 
should be covered. The Plan denied your request. The Plan says this chiropractic service is excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided by a chiropractor on June 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64635 billed for date of service April 19, 
2023.  
 
You asked the Plan to pay for procedure code 64635. You say that the enrollee has not exceeded sessions for 
the year. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64635 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64635 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64635 billed for date of service April 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
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 documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81433 billed for date of service May 25, 
2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the enrollee's physician ordered genetic 
testing due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The Plan says 
procedure code 81433 is considered unbundled as it was a part of the same panel and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81433 is hereditary breast cancer-related disorders (eg, 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion 
analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11. 
 
We looked at the file and Medicare rules. Medicare says if a single procedure is performed, only one code with 
one unit of service may be reported for the procedure. The Plan approved payment for CPT code 81432 
(hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary 
endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always 
including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53).  Based on this 
information, we decided that Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81433 billed for date of service May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87481 for April 5, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 5 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 3 units of CPT code 87481. 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 pay for the laboratory 
services billed with code 87481 for April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ViviGen allograft (20930). 
 
You asked the Plan to pre-approve the ViviGen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ViviGen Allograft in the setting 
of lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 ViviGen 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 requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 ViviGen allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ViviGen allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided 
on June 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
inhalation of nitrous oxide/analgesia (D9230) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on May 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental services should be covered under your 
benefits. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the comprehensive periodontal evaluation is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on May 22, 2023.