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

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that there is no indication 
that the enrollee has tried and failed the required drug(s). Based on the medical records provided and the 
Medicare-approved major drug compendia, there is no indication that the Plan's required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service October 28, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that the services at 
issue are billed correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is 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 codes 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 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 codes 88341, 88342, 88360 and 88381 billed for date of service October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on November 23, 
2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy provided on November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device provided on January 9, 
2023. 
 
You asked the Plan to pay for the Cala Trio device. You say that the enrollee has been using the Cala Trio 
device with improvements and control over essential tremor in hands. You also say this should be covered. The 
Plan denied your request. The Plan says the device 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 pay for the Cala Trio device. Our reviewer says that 
the Cala Trio device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not support that the Cala Trio device meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Cala Trio device have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cala Trio nerve stimulator device provided on January 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 23, 2022, 
through April 29, 2022, and billed with secondary diagnosis code G93.41. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis G93.41 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, -Metabolic 
Encephalopathy. 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of G93.41, -Metabolic Encephalopathy. Our physician reviewer found there was no clinical or 
laboratory evidence of metabolic encephalopathy. The review has determined that the documentation did not 
support secondary diagnosis code G93.41, -Metabolic Encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 23, 2022, through April 29, 2022, and billed with secondary 
diagnosis code G93.41.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs the requested 
bed due to sequelae cerebral infarction. The Plan denied your request. The Plan says the requested hospital bed 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an intraoral - complete series of radiographic images (D0210) provided 
on January 16, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that you were 
assured you had good dental coverage and all services would be covered. The Plan denied your request. The 
Plan says that the frequency limitation on this procedure code has been met and it is not covered by the 
supplemental dental benefit. 
 
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, we requested a copy of the Medicare quick reference guide from 
the Plan. The Plan did not send the Medicare quick reference guide to show the intraoral - complete series of 
radiographic images frequency limitation. Without this document we cannot determine whether the enrollee 
meets coverage for the intraoral - complete series of radiographic images. Therefore, we decided that the Plan 
has to pay for an intraoral - complete series of radiographic images (D0210) provided on January 16, 2023. 
  
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 osseous surgery (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that this is medically necessary. The Plan denied 
your request. The Plan says the code your dentist sent must have at least four teeth in the same part of the 
mouth that need treatment. The x-rays your dentist sent do not show you have four teeth that need treatment. 
 
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 osseous 
surgery 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 osseous surgery. Our reviewer says that 
the service does not meet the required criteria. Our physician reviewer found the documentation provided did 
not show that there are four or more teeth or implants in these quadrants that need osseous surgery. The radiographs provided did not show osseous defects around four or more teeth or implants requiring surgery and 
there was no narrative indicating the need for the procedure. 
 
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 osseous surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve osseous surgery (D4260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit provided on 
January 13, 2023. 
 
You asked the Plan to waive the copayment for the primary care office visit. You say that this was an annual 
physical exam and should have no copayment. 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 $15 
copayment for primary care physician/practitioner services. 
 
You have been asked to pay a $15 copayment for the primary care office visit. This item/service falls within 
the primary care physician/practitioner services 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 records show this visit was a follow-up and not an annual 
physical exam. Therefore, we decided that the Plan does not have to waive the copayment for the primary care 
office visit provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses, the tint, the anti-reflective coating, 
and the polycarbonate lenses provided on May 13, 2022. 
 
You asked the Plan to pay for the progressive lenses, the tint, the anti-reflective coating, and the polycarbonate 
lenses. You say that you would like to be reimbursed for the lenses you received. The Plan denied your request. 
The Plan says the defective lenses were replaced at no charge and the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover these items. 
 
We looked at the file and the Plan's rules. Specifically, the items are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lenses, the tint, the anti-reflective 
coating, and the polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to 
pay for the progressive lenses, the tint, the anti-reflective coating, and the polycarbonate lenses provided on 
May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that COPD is mentioned occasionally in the record, but there are no pulmonary function tests to support that 
diagnosis. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 chiropractic manipulative treatments (98941). 
 
You asked the Plan to pre-approve these services. You say that chiropractic manipulative treatments are 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have chronic back pain in the setting of cervical, thoracic, and lumbar segmental dysfunction. 
The records of these visits do not support progressive improvement of symptoms but rather maintenance 
therapy. The requested services are maintenance therapy. The elements of the coverage criteria are not 
satisfied. The requested services are not recommended. 
 
  
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve 3 chiropractic manipulative treatments (98941).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a partial payment for one crown - porcelain fused to high noble 
metal D2750. We also decided that the Plan does not have to pre-approve crowns - resin-based composite 
tooth #'s 6, 7, 11, 24, 25, and 28 D2710, and the full cost of one crown - porcelain fused to high noble metal 
D2750.  
 
You asked the Plan to pre-approve crowns - resin-based composite (indirect) tooth #'s 6, 7, 11, 24, 25, and 28 
D2710, and crown - porcelain fused to high noble metal tooth #'s 11 and 28 D2750. You say that you were 
given notice that the denial is for not submitting x-rays and narrative with the treatment request, and that the 
dentist already sent these to the Plan. The Plan says that crown - resin-based composite (indirect) D2710 is 
denied because it is not covered by the Plan. The Plan also says that your benefit for the D2750 has been 
denied for exceeding your available balance. 
 
We decided that the Plan has to pre-approve partial payment for one crown - porcelain fused to high 
noble metal D2750.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence provided showing that you have met your annual maximum $3,000 per 
year for supplemental comprehensive dental services. Therefore, we decided that the Plan has to pre-approve a 
partial payment for one crown - porcelain fused to high noble metal D2750.  
 
We also decided that the Plan does not have to pre-approve crown - resin-based composite (indirect) 
tooth #'s 6, 7, 11, 24, 25, and 28 D2710, and the full cost of one crown - porcelain fused to high noble 
metal D2750. 
 
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 crowns - resin-based composite 
(indirect) tooth #'s 6, 7, 11, 24, 25 and 28 are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve crown - resin-based composite (indirect) tooth #'s 6, 7, 11, 
24, 25, and 28 D2710. Since the Plan is paying a partial payment for one crown you have met your $3,000 
annual maximum benefit. Therefore, we decided that the Plan does not have to pre-approve  one crown - 
porcelain fused to high noble metal D2750. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, 
through April 28, 2022, and billed with diagnosis code A41.59. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.59 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.59. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.59 Other Gram-
negative sepsis. 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the primary 
diagnosis of A41.59, Other Gram-negative sepsis. Our physician reviewer found the member presented with a 
catheter-associated urinary tract infection and an infected sacral decubitus ulcer. The member was treated with 
intravenous ceftriaxone and intravenous ceftriaxone antibiotics. In this case, there was no laboratory or clinical 
evidence of sepsis. The review has determined that the documentation did not support the primary diagnosis 
code A41.59 Other Gram-negative sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 11, 2022, through April 28, 2022, and billed with diagnosis 
code A41.59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the removal of residual tooth roots (cutting procedure) 
(D7250) provided on September 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are supposed to pay 50% only, which 
would be less than $158. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the removal of residual tooth roots (cutting 
procedure) (D7250) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941), office 
visits (99203), and the durable medical equipment (E1399) provided from August 23, 2022, through  
November 14, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services provided are not a 
covered benefit. 
 
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 record shows that the items/services provided in this case are not covered by Medicare or the Plan. 
Specifically, the Plan contract states that the only covered chiropractic service is manual manipulation of the 
spine to correct a subluxation. The chiropractic services in this case were performed for the treatment of 
neuropathy. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative 
treatments (98941), office visits (99203), and the durable medical equipment (E1399) provided from  
August 23, 2022, through November 14, 2022.