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

 
We decided that the Plan does not have to pre-approve retainer crown tooth 18 and 20 (D6751) and a pontic 
tooth 19 (D6241). 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
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 based off the limited clinical documentation included, D6751 for teeth number 18 and 20, and D6241 for tooth number 19 is not medically 
necessary. 
 
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 tooth 18 and 20 (D6751) and a pontic tooth 19 (D6241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array (Sprint PNS) (64555).  
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is covered by Medicare and should be 
approved. 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 the Sprint PNS. Our reviewer says that 
the requested Sprint PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy for low back pain as it is the subject of ongoing clinical 
trials. The reviewer found that the enrollee is not in a clinical trial. Therefore, the reviewer found that the 
requested Sprint PNS is not medically reasonable and 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous implantation of neurostimulator electrode array (Sprint PNS) (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis (22614, 22600), the posterior segmental 
instrumentation (22843), and the laminectomy with exploration and/or decompression of spinal cord and/or 
cauda equina (63015).  
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee has developed L'hermitte 
sign with numbness and tingling with jolting pain down their arms and legs when moving their head. The 
appellant says the enrollee's imaging shows instability at both C3-4 and C4-5 levels.  The Plan denied your 
request. The Plan says the arthrodesis, posterior segmental instrumentation, and the laminectomy are not 
medically necessary. The Plan says the radiographic findings do not show instability or cord compression.  
 
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 surgical services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for cervical spine stenosis. The documentation is not clearly 
evident regarding cervical pathology that could benefit from the requested procedure. The imaging did not 
reveal segmental instability. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the arthrodesis (22614, 22600), the posterior segmental instrumentation (22843), 
and the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (63015).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the best fit for the enrollee. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that the enrollee is still requiring sedation and is not medically stable for transfer to 
an LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 30, 2023, billed with codes 
87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. 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 lab testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
May 30, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2330 x 4, D2331, D2391, 
D2392) provided from May 10, 2023, to May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed your benefit was 
exhausted prior to the visits. 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 on date of service May 22, 2023. Therefore, 
we decided that the Plan does not have to pay for the resin-based composites (D2330 x 4, D2331, D2391, 
D2392) provided from May 10, 2023, to May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee does not 
qualify for a home ventilator or respiratory assist device because there is no chronic carbon dioxide (CO2) 
retention. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64454). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve block 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for procedure code 90999 provided from May1, 
2023, to May 31, 2023. 
 
You asked the Plan to pay additionally for procedure code 90999. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. The rules say that, for dialysis sessions that have been furnished 3 times 
(3X) per week, each line should be 90999 without any modifiers appended. For each dialysis session furnished 
in addition to 3 sessions per week that includes medical documentation supporting a reasonable and necessary 
determination for payment, each line for these services should be billed as 90999 KX. 
 
We looked at the file and Medicare rules. The file shows that procedure code 90999 was incorrectly billed. 
Therefore, we decided that the Plan does not have to pay additionally for procedure code 90999 provided from 
May1, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on May 4, 2023. 
 
You asked the Plan to pay for the office visit. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says The Plan says the only covered chiropractic service is manual manipulation of the 
spine. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary due the 
amount of pain the enrollee is in. You say that the enrollees last epidural steroid injection provided 60% pain 
relief for three weeks. The Plan denied your request. The Plan says an epidural steroid injection 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 the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the medical records 
does not document that the enrollee has had at least 50% of sustained improvement in pain relief or 
improvement in function measured from baseline using SAME scale for at least three months. Also, there is no 
documentation that the provider will be using different medications. Therefore, the request does not meet the 
LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Udenyca. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee's condition is not an FDA-
approved indication for this medication. It is being used off-label. The drug compendia were searched current 
literature, and insufficient support was made for this off-label use. There was no documentation showing 
evidence of the enrollee having a covered indication such as non-myeloid malignancy or acute radiation 
syndrome. The documentation does not sufficiently support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint 
(64625). 
 
You asked the Plan to pre-approve RFA of the sacroiliac joint. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA of the sacroiliac joint. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy because of the wide variation in 
efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable and 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 RFA of the sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and abutment supported 
crown (D6058) provided on June 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that crowns are a covered benefit, and your annual 
allowance covers these procedures. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental 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. 
 
 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 pay for the 
prefabricated abutment (D6056) and abutment supported crown (D6058) provided on June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device (22840, 22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure at L4-S1. 
 
You asked the Plan to pre-approve the Intracept procedure at L4-S1. You say that the Intracept procedure is 
safe and effective for treating the enrollee's chronic back pain. The Plan denied your request. The Plan says the 
Intracept procedure is not medically necessary. The Plan says the enrollee's back pain is due to the presence of 
non-vertebrogenic pathology and no documentation of Modic changes.  
 
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 Intracept procedure at L4-S1. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication and presented with lower back pain. The documentation shows that there are multiple plausible pathologic sources of significant pain generation. Also, the provided magnetic resonance imaging 
(MRI) does not corroborate Modic changes at the requested procedure levels.  
 
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 Intracept procedure at L4-S1 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Intracept procedure at L4-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray and an office visit provided by a chiropractor on 
June 14, 2023. 
 
You asked the Plan to pay for an x-ray and an office visit. You say that you know that x-rays are covered for 
other doctors. The Plan denied your request. The Plan says The Plan says the only covered chiropractic service 
is manual manipulation of the spine. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an x-ray and an office visit provided by a chiropractor on June 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Keytruda is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.