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

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the vertiflex device 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 the vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nebulizer, with compressor provided on 
January 14, 2023. 
 
You asked the Plan to waive the coinsurance for a nebulizer, with compressor. You say that this item has 
already been paid off. 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 20% 
coinsurance for in-network Medicare-covered equipment and supplies. 
 
You have been asked to pay 20% coinsurance for a nebulizer, with compressor. This item/service falls within 
the in-network Medicare-covered equipment and supplies 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. The total you owe is $1.49 ($7.46 allowed amount 
x 20% = $1.49). Therefore, we decided that the Plan does not have to waive the coinsurance for a nebulizer, 
with compressor provided on January 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep-study (95811). 
 
You asked the Plan to pre-approve a sleep study. 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 a sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a remote history of obstructive sleep apnea, which was apparently never 
treated. The enrollee is having symptoms of obstructive sleep apnea (OSA), with an Epworth score of 15. The 
body mass index (BMI) is 31.7. There is no history of severe cardiac or pulmonary disease. A home sleep test 
would be reasonable for this enrollee, with initiation of auto titrating continuous positive airway pressure 
(CPAP) if OSA is confirmed. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep-study (95811).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary, and 
the level of care needed cannot be met in a lower level. The Plan denied your request. The Plan says the 
enrollee can safely receive this care in the hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 15, 2021, to 
September 11, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the RAP was not submitted 
within the required 5-day period. 
 
The Plan follows Medicare rules. Medicare rules say that home health agencies must submit the RAP within 5 
calendar days of the start date or from date for each 30-day period of care. 
 
We looked at the file and Medicare rules. This RAP was not submitted within 5 calendar days of the start date 
for this period of home health. Based on this information, we decided that Medicare rules for coverage of home 
health care have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from August 15, 2021, to September 11, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on February 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered when 
billed with type of bill (TOB) 327. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the claim, and Medicare rules. The file shows that the claim was billed with type of bill 
327 correctly. The claim shows that this was submitted as a corrected claim. Therefore, we decided that the 
Plan has to pay for the home health services provided on February 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223) provided on December 15, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the claim was not billed with 
a valid diagnosis code. Codes J44.1 and J47.9 have an exclude note and cannot be billed together. Based on this 
information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient care (99223) provided on December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 26, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 76770 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 26, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the care and services required by the 
enrollee exceeds the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan 
says when the enrollee is ready to leave the hospital, they can safely receive this care in another setting, such as 
a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bridge (D6245, D6740 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 a 
bridge (D6245, D6740 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87636 provided on January 25, 2023. 
 
You asked the Plan to pay for procedure code 87636. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87636 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87636 
provided on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. 
 
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that the requested test strips are 
medically necessary for the enrollee. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite 
test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown-porcelain fused high noble tooth 17, 21, 29, 32 
(D6750) and pontic-porcelain fused-high noble tooth 18, 19, 20, 30, 31(D6240). 
 
You asked the Plan to pre-approve crown and pontic. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is not meeting the approval criteria for bridge. To approve a 
bridge, you must be missing only one upper front tooth or only two lower front teeth. The two lower front teeth 
must be next to each other. You also cannot be missing any of your back teeth. Our dentist looked at the x-rays 
your dentist sent us and said you are missing other teeth. 
 
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 crown and 
pontic 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 crown and pontic. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found according to the guidelines, fixed 
bridges are considered for coverage if they are replacing a single maxillary anterior tooth or two adjacent 
mandibular anterior teeth when no posterior teeth are missing. In this case, the missing teeth being replaced are 
posterior teeth. 
 
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 crown and pontic have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crown-porcelain fused high noble tooth 17, 21, 29, 32 (D6750) and pontic-porcelain 
fused-high noble tooth 18, 19, 20, 30, 31(D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroscopic rotator cuff repair, extensive 
debridement, distal claviculectomy, subacromial decompression with partial acromioplasty, and biceps 
tenodesis. 
 
You asked the Plan to pre-approve the arthroscopic rotator cuff repair and associated procedures. You say that 
the services are medically necessary. The Plan denied your request. The Plan says the services are 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 arthroscopic rotator cuff repair and 
associated procedures. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. The previous 
injections were not documented to be recent. There is no documentation of any other forms of conservative 
care for the chronic shoulder pain. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. No compelling rationale is 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 arthroscopic rotator cuff repair and associated procedures have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the arthroscopic rotator cuff repair, 
extensive debridement, distal claviculectomy, subacromial decompression with partial acromioplasty, and 
biceps tenodesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown, porcelain/ceramic tooth #18, #21, #28, 
#31 (D6740) and pontic tooth #19, #20, #29, #30 (D6245). 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation received fails to indicate any specific 
needs or conditions that preclude use of a removable prosthesis. According to the member's evidence of 
coverage, there is coverage for bridges (fixed prostheses). However, there are certain criteria that MUST be 
met, the placement of a fixed prosthetic appliance will ONLY be considered for those exceptional cases where 
there is a documented physical or neurological disorder that would preclude placement of a removable 
prosthesis. 
 
 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 retainer 
crown and pontic 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 retainer crown and pontic. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found in this instance there has been no 
showing of a documented physical or neurological disorder indicated or documented in the record.  As the Plan 
does not routinely allow for fixed bridgework, the requested treatment is not medically necessary as it does not 
meet criteria. 
 
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 retainer crown and pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown, porcelain/ceramic tooth #18, #21, #28, #31 (D6740) and 
pontic tooth #19, #20, #29, #30 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve radiofrequency ablation (RFA) 
(64624). 
 
You asked the Plan to pre-approve the genicular nerve RFA. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service 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 the genicular nerve RFA. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental 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 genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the genicular nerve radiofrequency ablation (RFA) (64624).
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. The Plan 
denied your request. The Plan says the therapy services the enrollee needs could be given in a skilled nursing 
facility.  
 
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 enrollee does 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.