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

 
We decided that the Plan does not have to pre-approve the ViviGen allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the enrollee needs to have the surgery for back 
pain. The Plan denied your request. The Plan says  the ViviGen allograft is not medically necessary. The Plan 
says the clinical value and effectiveness of the ViviGen allograft in an anterior cervical spine fusion surgery 
have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the 
specific request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested allograft would be as safe or better than standard autograft procedures. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested ViviGen allograft is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ViviGen allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, upgraded electronics, inner liner, and foot plate connector. 
 
You asked the Plan to pre-approve the upgraded electronics, foot plate connector, and inner liner. You say that 
this is medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show 
a medical need to control the power options through the joystick. The Plan says that the foot plate connector is 
miscoded and therefore cannot be covered. The Plan also says the approved seat cushion includes all parts 
needed for it to work correctly. 
 
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 upgraded electronics, foot plate 
connector, and inner liner. Our reviewer says that the requested upgraded electronics, foot plate connector, and 
inner liner are not considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation indicates the enrollee has sufficient strength and function in upper extremities 
to manage standard power drives. The reviewer found that the requested liner is included in the approved seat 
cushion. The reviewer also found that while the requested foot plate connector may be necessary, the Plan has 
already approved a center mount power elevating leg rest/platform. Therefore, the reviewer found that the 
requested upgraded electronics, inner liner, and foot plate connector are 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 upgraded electronics, foot plate connector, and inner liner have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with 
multiple power options, upgraded electronics, inner liner, and foot plate connector.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits to be provided by an OON provider. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of additional 
physical therapy visits beyond the 8 that was already approved. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the requested physical therapy is generally accepted as a specific 
and effective therapy for fibromyalgia. There is no clinical documentation regarding the enrollees progress and 
need for ongoing physical therapy with the current provider. There is also a lack of documentation indicating 
why the enrollee requires out-of-network coverage for a different physical therapy provider from a medical 
standpoint. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional PT visits to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the prescription drug (S5000) purchased out 
of the country on February 3, 2023.   
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the billed code for this item is 
invalid for Medicare purposes. Additionally, prescriptions purchased outside of the country are not covered 
even for urgent or emergency care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. Additionally, the Plans contract says that 
prescriptions purchased outside of the country are not covered even for urgent or emergency care.  
 
We find that procedure code S5000 has a Status Indicator of I on the Physician Fee Schedule. This means that 
this procedure code is not valid for Medicare purposes. Additionally, the Plans contract states that 
prescriptions purchased outside of the country are not covered even for urgent or emergency care. Based on 
this information, we decided that Medicare and the Plans rules for coverage of this item have not been met. 
Therefore, we decided that the Plan does not have to issue reimbursement for the prescription drug (S5000) 
purchased out of the country on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), a harness (E2313), electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), and extra 
link for headrest hardware (K0108). 
 
You asked the Plan to pre-approve an expandable controller, a harness, electronic connection, and extra link for 
headrest hardware. You say that the services are necessary. The Plan denied your request. The Plan says that 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 expandable controller, a harness, 
electronic connection, and extra link for headrest hardware. Our reviewer says that the requested items/services 
are considered medically reasonable and necessary in this case. Our physician reviewer found the complexity 
of her seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options via a joystick. These components are required to operate 3 or more 
power options on a group 3 power wheelchair. The hardware is also necessary for mounting of the enrollee's 
headrest, which is required when the power wheelchair is reclined. Therefore, the expandable controller 
(E2377) with harness (E2313) and electronic connection (E2311) and headrest hardware (K0108) are medically 
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 an expandable controller, a harness, electronic connection, and extra link for 
headrest hardware have been met. Therefore, we decided that the Plan has to pre-approve an expandable 
controller (E2377), a harness (E2313), electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), and extra link for headrest hardware (K0108).   

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 dental code D4266 for teeth #4, 6, 11, and 15. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
correct code has not been requested. 
 
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 D4266 is guided tissue regeneration of natural teeth.  
 
We find that CPT code D4266 is not supported. There is a more accurate code available that describes the 
services requested. Based on this information, we decided that Medicare rules for coverage of the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental code 
D4266 for teeth #4, 6, 11, and 15.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the detailed documentation is evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay. Therefore, the record does show that the admitting physician reasonably expects that the 
enrollees necessary hospital care will span two midnights with supporting documentation of the enrollee's 
history and comorbidities, signs and symptoms, current medical needs, and risk for a n adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 10, 2022, billed 
with codes U0004, 87502, 87498, 87631, 87483 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 10, 2022, billed with codes U0004, 87502, 87498, 87631, 87483 and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for bilateral L4-L5 laminectomy 
fusion surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that surgical intervention is indicated at this 
time. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate 
in the setting of spinal fusion surgery have not been demonstrated. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current peer-reviewed medical literature does no support that bone marrow aspirate 
results in long-term health benefits in patients with lumbar spondylosis with chronic low back pain and lower 
extremity radiculopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for bilateral L4-L5 laminectomy fusion surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99233 
billed on June 25, 2022. 
 
You asked the Plan to pay for 99233. You say that 99233 billed on June 25, 2022, should be paid as billed 
because it is supported in the medical record. The Plan denied your request. The Plan says 99233 billed on June 
25, 2022, is denied because it is not supported in the medical record. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say for Medicare to consider 
coverage for any item or service, the information submitted by the provider must corroborate the 
documentation in the medical record and confirm that Medicare coverage criteria has been met. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the records show an exam 
with a listed date of service as June 25, 2022, but the same exam documentation also lists the service date as 
June 24, 2022. Consequently, there is conflicting information regarding when the exam took place, and the 
actual date of the exam cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of 99233 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services coded as 99233 billed on June 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 14, 2023, to April 27, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. The bone graft replacement is not a covered service. Therefore, we decided that the Plan does not have to pay for dental services provided on February 14, 2023, to 
April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 19, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that medical records were provided. The Plan denied 
your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen.  
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. We find that code 96521 is not supported in the record. The documentation shows that 
an order was placed for the maintenance and refill of a portable pump. However, the records do not document 
this service was provided. We find that code J1817 is not supported. There is a more accurate code available to 
describe the injection services provided. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Outpatient 
Intravenous Insulin Therapy (OIVIT) services provided on April 19, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that the Plan requires a trial of one oral and one intravenous bisphosphonate before it 
will approve Prolia. 
 
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. Medicare covers Part B medications when they are reasonable and necessary but allows health plans 
to implement step therapy criteria. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit related medical records for review. We requested 
supporting medical records, but none were sent to us. Without this information, we cannot determine whether 
the enrollee may meet an exception to the Plans step therapy criteria. Therefore, the Plan has not shown that its 
decision to deny authorization for this drug is correct. Therefore, we decided that the Plan has to pre-approve 
use of Prolia.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 27 additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are medically 
necessary for you to get to your appointments. The Plan denied your request. The Plan says your benefit allows 
24 trips for this service, and you currently have 1 trip remaining and you will have exceeded your benefit limit. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 27 additional transportation trips.