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

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet 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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of anemia due to chemotherapy. The documentation does not support that the 
enrollee has tried and failed Retacrit or Procrit. The documentation does not support that Retacrit or Procrit 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. There is no discussion of spinal instability on flexion/extension films. Height is 62 inches, weight is 
200 pounds, and body mass index is 36.58 kg/m2. There is no discussion of scoliosis of the lumbar spine with 
no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the 
lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous spacer at the L2-3 and L3-4 levels, in this case, is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the lower partial denture-cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
on December 16, 2022. 
 
You asked the Plan to issue additional payment for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the item provided 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the item provided was exhausted on date of service December 16, 2022.   
 
Specifically, the Plans contract states that the annual maximum dental benefit is $3,000. The record shows that 
you have exhausted the maximum allowable dental benefit as of December 16, 2022. Therefore, we decided 
that the Plan does not have to issue additional payment for the lower partial denture-cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on December 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration, endosteal implant, 
prefabricated abutment, and bone replacement graft (D7953, D4266, D6010, D6056). 
 
You asked the Plan to pre-approve 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 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 
guided tissue regeneration, endosteal implant, prefabricated abutment, and bone replacement graft (D7953, 
D4266, D6010, D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) December 15, 2022. 
 
You asked the Plan to pay for dental services. You say that you feel these services should be covered by your 
insurance. The Plan denied your request. The Plan says these services are not covered under your Plan. 
 
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. Limited oral evaluation - 
problem focused (D0140) and intraoral - periapical first radiographic image (D0220) are not covered under the 
Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140 and D0220 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided on 
December 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that a consideration should be made to allow cover 
for the denture prior to the allowed frequency. The Plan denied your request. The Plan says your benefit for the 
requested item or service 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 Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the complete denture  maxillary was exhausted on date of service June 7, 2018. 
Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided 
on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional retainer crown (D6751). 
 
You asked the Plan to pre-approve 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 your benefit for the requested item or 
service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the Plans authorization from March 
21, 2023, to June 19, 2023. Therefore, we decided that the Plan does not have to pre-approve an additional 
retainer crown (D6751).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the acupuncture treatments (97810, 97811) provided 
from September 28, 2022, through October 28, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services 
are not payable as the provider does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the acupuncture services provided are not 
payable as the provider in this case does not meet Medicare criteria for coverage. However, the Plan provides 
supplemental coverage for acupuncture services. The Plan has not indicated that you do not meet criteria for 
coverage of these services through the supplemental benefit. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the 
acupuncture treatments (97810, 97811) provided from September 28, 2022, through October 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cost sharing 
provided from September 15, 2022, to December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were charged for an evaluation that never 
happened. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the D0120 was exhausted on dates of service July 18, 2022, and September 15, 2022. 
Additionally, all cost sharing was charged correctly. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120) and cost sharing provided from September 15, 2022, to December 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on  
June 6, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that the coverage is provided 
for hearing aids only when purchased from the Plans select hearing aid provider. However, the hearing aids in 
this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5298) purchased on June 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed with Patient-
Driven Payment Model (PDPM) NKGE1 for date of service December 23, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the SNF services billed with PDPM NKGE1. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan follows Medicare rules. Medicare rules say that SNF services must be billed with the correct PDPM. 
 
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 SNF services billed with PDPM 
NKGE1. Our reviewer says that the documentation does not support the PDPM billed. Our physician reviewer 
found the enrollee was admitted to the skilled facility. The medical record has a physician's order dated 
December 23, 2021 and signed by the physician on the same date that shows the enrollee is to have a diet of 
cardiac, mechanical soft, thin liquids. A physician order is an intent of treatment. An order does not indicate 
that the task will be or has been carried out, only that the intent is for it to be carried out. As such, an order by 
itself cannot be used to support the coding of a mechanically altered diet. There would need to be 
documentation for between the dates of December 23, 2021, to December 27, 2021, to show that the enrollee 
actually received the mechanically altered diet. The documentation must be within the specified look back 
period in order to accept for any item coding. The registered dietician documentation for December 30, 2021, 
and the documentation from speech therapy for January 5, 2022, are all for dates well after the assessment 
reference date of December 27, 2021, and, therefore, cannot be used for support of the coding of the minimum 
data set (MDS) item K0510C2: Mechanically Altered Diet while a resident. As the medical records provided 
have no documentation found for the look back of December 23, 2021, to December 27, 2021, showing that a 
mechanically altered diet was administered to the member, then the coding cannot be supported.  
 
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 SNF services billed with PDPM NKGE1 have not been met. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed with Patient-
Driven Payment Model (PDPM) NKGE1 for date of service December 23, 2021, to December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220), panoramic radiographic image (D0330) and pulpal debridement 
primary and permanent teeth (D3221) provided on December 12, 2022, and December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that it is your understanding that your insurance 
covers these services, and you will be reimbursed. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. Limited oral evaluation - 
problem focused  and pulpal debridement primary and permanent teeth are not covered under the Plans dental 
benefits under any circumstance. This benefit includes coverage for the requested items or services, but only 
when they are received from an in-network provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140 and D3221are not 
among those covered under this benefit under any circumstance.  
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested D0220 and D0330 are not covered under 
this benefit when received from an out-of-network provider.  
 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220), panoramic radiographic image (D0330) and 
pulpal debridement primary and permanent teeth (D3221) provided on December 12, 2022, and December 15, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 7, 2022. 
 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 claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the provider was 
out-of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this device is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that 
this device is not medically necessary. Our physician reviewer found the provided records in this case 
document Chronic Obstructive Pulmonary Disorder (COPD) and weakness of the diaphragm, but records do 
not document a diagnosis of cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a 
high frequency chest wall oscillation device may be covered. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 17, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 17, 2022, to 
March 31, 2022.