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

 
We decided that the Plan does not have to pre-approve interim crowns (D2799) for tooth #7, #8, #9, #10, #11, 
and #12. 
 
You asked the Plan to pre-approve the dental services. You say that you are missing half of the work for your 
teeth. The Plan denied your request. The Plan says temporary crowns are services included in the allowance of 
the permanent crowns; therefore, the denial for temporary crowns is correct. 
 
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 interim crowns (D2799) as presented are not medically necessary. Our physician reviewer found that 
there are only 4 remaining upper teeth, including tooth #8, #9, #12, and #15. The requested treatment is 
apparently for a multi-unit bridge, replacing tooth #7, #10, and #11. The codes provided are to be used for 
temporization of an affected tooth while determining a final treatment plan. The codes are not designed to be 
used for making a temporary bridge which includes missing teeth. In general, if a bridge is to be fabricated, the 
temporization of the teeth while the bridge is being made is included in the treatment code for each individual 
unit of that bridge. 
 
The Plan does not provide coverage for the requested treatment. A temporary bridge is not allowable under the 
provided code for single unit temporization. The codes are being applied to missing teeth that will be part of 
the bridge as well, and this is not the proper use of that code. Individual teeth that require temporization while 
determining final possible treatments (e.g., when the tooth is severely broken down and other treatment is 
needed first or may need endodontic treatment that may be questionable etc.). The bridge codes that would be 
properly used would be inclusive of any temporization for a bridge procedure. There has been no showing that 
the teeth in question #8, #9, and #12 are in need for further evaluation to make a treatment plan. Teeth #7, #10, 
and #11 are missing and cannot be temporized, only added to a bridge. The requested treatment is therefore not 
a covered service under the Plan. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve interim crowns (D2799) for tooth #7, #8, #9, #10, #11, and #12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory/pathology services (83020) provided on 
December 22, 2022. 
 
You asked the Plan to pay for laboratory/pathology services. You say that these services were necessary and 
were reported appropriately. The Plan denied your request. The Plan says this claim was submitted with an 
incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services provided to a patient who is registered inpatient or outpatient of a hospital, the 
correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS code or that of the appropriate outpatient hospital POS code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory/pathology services have not been met. Specifically, this claim was submitted with POS 
code 22 (On Campus-Outpatient Hospital). However, the record shows that the enrollee was registered 
inpatient status from December 14, 2022, until January 3, 2023. This means that the appropriate POS code 
would be an inpatient hospital code. Therefore, we decided that the Plan does not have to pay for 
laboratory/pathology services (83020) provided on December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this procedure is considered 
experimental. 
 
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 an Intracept procedure. 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 magnetic resonance imaging showing only modic changes and no facet 
joint disease or stenosis. The cause of pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is 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 the home ventilator. Our physician 
reviewer found the record indicates the order is for average volume-assured pressure support (AVAPS) -AE. The home ventilator is not medically necessary to provide AVAPS AE - this can be done with a bilevel positive 
airway pressure (BiPAP). The medical necessity of the choice of home ventilator over a BIPAP is not 
supported in the record.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you struggle with mobility and are in intense pain. 
You also say that you are getting an epidural soon and need the scooter to be able to move around. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 a scooter. Our reviewer says that a 
power scooter (K0800) is not medically necessary. Our physician reviewer found you are noted to have lumbar 
radiculopathy with lumbar degenerative disc disease and right sided knee arthritis. However, there is a lack of 
clinical documentation indicating your level of mobility and physical examination findings, specifically with 
regards to motor strength in the upper and lower extremities. Our reviewer found that there is no indication that 
you cannot use a cane or walker for assistance with mobility or propel a manual wheelchair. Our physician 
reviewer also found that there is a lack of information as to whether you can safely operate the requested group 
1 power mobility device and if your home is accessible for it. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 5, 2022, billed 
with evaluation and management (EM) code 99292. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records provided does not 
include sufficient documentation to validate that Critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) 
was performed on September 5, 2023, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 5, 2022, billed with evaluation 
and management (EM) code 99292.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is 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 the home ventilator. Our physician 
reviewer found  the average volume-assured pressure support (AVAPS) can be provided with a bilevel positive airway pressure (BiPAP). The medical necessity for a home ventilator rather than BIPAP is not supported in 
the record. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intercept procedure performed at L3-L4. 
 
You asked the Plan to pre-approve an Intercept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the physical exam and 
radiologic studies show additional significant pathologies that are unlikely to benefit from the procedure. 
 
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 an Intercept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found physical exam suggests that the facet joints are the cause of the back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intercept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intercept procedure performed at L3-L4.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming of 
sensing and therapeutic parameters; pulse generator with transvenous electrodes-implantation of a cardiac 
contractility modulation system in the form of the Optimizer Smart device (CCM).  
 
You asked the Plan to pre-approve implantation of a cardiac contractility modulation system, the Optimizer 
Smart device (CCM). You say that the implantation of a cardiac contractility modulation system is medically 
necessary. The Plan denied your request. The Plan says implantation of a cardiac contractility modulation 
system, Optimizer Smart device (CCM) is experimental, investigational and unproven.  
 
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 implantation of a cardiac contractility 
modulation system, the Optimizer Smart device (CCM). Our reviewer says that the requested implantation of a 
cardiac contractility modulation system, the Optimizer Smart device (CCM) is not considered medically 
reasonable and necessary. Our physician reviewer found that the enrollee has left ventricular dysfunction with 
continued symptoms, despite medical treatment, thought to reflect congestive heart failure. An exhaustive 
review of the current medical literature pertaining to the CCM system confirms multiple observational studies 
suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been 
reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful 
improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to the 
U.S. Food and Drug Administration (FDA) approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, I would not consider the CCM system to be medically necessary for this 
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 implantation of a cardiac contractility modulation system, the Optimizer Smart 
device (CCM) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
implantation of a cardiac contractility modulation system, the Optimizer Smart device (CCM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve the thermal destruction of intraosseous basivertebral nerve. You say that the 
enrollee has failed conservative treatment without relief. The Plan denied your request. The Plan says the 
medical 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 the thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there were/are multiple plausible 
pathologic sources of significant pain generation. The non-radiating back pain, the diminished and painful 
spinal motion, and the intact neurologic exam were/are all non-specific to any pathologic entities. 
 
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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous 
basivertebral nerve.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the outpatient surgery, laboratory 
service, and office visit provided from January 23, 2023, to February 2, 2023. 
 
You asked the Plan to waive the cost sharing amounts for the outpatient services. You say that you should not 
be responsible for these bills. 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 10% 
coinsurance for Outpatient surgery, a $10 copayment for Outpatient diagnostic testing, and a $35 copayment 
for specialist services. Your contract with the Plan also says that there is a $525 deductible which applies to 
covered in-network medical services. 
 
You have been asked to pay a 10% coinsurance for outpatient surgery. This service falls within the Outpatient 
surgery benefit category. You have been asked to pay a $10 copayment for the laboratory service. This service 
falls within the Outpatient diagnostic testing benefit category. You have been asked to pay a $35 copayment for 
the office visit. This service falls within the Physician/Practitioner services benefit category. This means that 
you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Additionally, the Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $525 deductible which applies to covered in-
network medical services. This cost sharing is a contractual obligation that had not been met at the time the 
outpatient surgery was received on January 23, 2023. Therefore, we decided that the Plan does not have to 
waive the cost sharing amounts for the outpatient surgery, laboratory service, and office visit provided from 
January 23, 2023, to February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 31, 
2023. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve participation in a study of gemcitabine, nab-paclitaxel, 
and bosentan. 
 
You asked the Plan to pre-approve clinical trial participation. You say that you want the strongest medication 
available. The Plan denied your request. The Plan says the Plan is not responsible for initial coverage of 
clinical trial services, instead Original Medicare covers the routine items and services received as part of the 
study. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve clinical trial participation as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve participation in a study of gemcitabine, nab-paclitaxel, and bosentan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
receive the therapy needed to return to your prior level of function. The Plan denied your request. The Plan 
says you do not meet the 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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.