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

We decided that the Plan does not have to provide coverage for dental services coded as D6057, D6010,
D5982 D6058 and D6740.
You asked the Plan to provide coverage for codes D6057, D6010, D5982, D6058 and D6740. You say that the
Plan should cover these dental services. The Plan denied your request.
The Plan says while a portion of these dental services were covered, the denied codes were not covered under
the Plan benefit or were not shown to be medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, the requested codes are not among those covered under this
benefit and/or your dental provider failed to submit dental records to establish necessity. Therefore, we decided
that the Plan does not have to provide coverage for dental services coded as D6057, D6010, D5982 D6058 and
D6740.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup services, a surgical stent, endosteal 
implant, custom fabricated abutment, and retainer crown (D2950, D6740, D6010, D6057, D6058, D5982. 
 
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 Plan's 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. Therefore, we decided that the Plan does not have to pre-approve core buildup services, a surgical stent, endosteal implant, custom fabricated abutment, and retainer crown (D2950, D6740, D6010, D6057, D6058, D5982.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested ventilator beyond the three
months approved by the Plan.
You asked the Plan to provide continued coverage for this ventilator. The Plan denied your request. The Plan
says while three additional months were approved, continued coverage beyond the three months is not
approved. Maximus partially overturned the Plans denial for three months of coverage. The Plan requested a
reopen and stated that Maximus made the same decision the Plan made.
The Plan is correct in this case. The Plan follows Medicare rules. Medicare has specific coverage criteria for
ventilators. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare
rules.
Our physician reviewer found continuation of a home ventilator is not medically necessary. The enrollee's
ventilator settings can be provided with bilevel positive airway pressure (BiPAP), and Medicare does not cover
a ventilator when used at settings that can be provided with BiPAP. The Plan has approved three additional
months to allow time for transition to BiPAP. Medicare criteria for continuation beyond the three months are
not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of the ventilator beyond the three months approved have not been
met. Therefore, we decided that the Plan does not have to pre-approve continued coverage for an E0466
ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment a mental health visit on December 28, 2022. 
 
You asked the Plan to reduce the copayment a mental health visit. You say that the copayment should be $10 
The Plan denied your request. The Plan says that 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 $10 
copayment for outpatient mental health care.  
 
You have been asked to pay a $10 copayment for a mental health visit. This item/service falls within the 
outpatient mental health care 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. Therefore, we decided that the Plan has to reduce the copayment a mental health visit on 
December 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87801 billed for date of service November 15, 2022. 

You asked the Plan to pay for procedure code 87801. You say that these services were necessary and are supported in the medical record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 

The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. 

In this case, the MUE for CPT code 87801 is 3. The MAI value for this code is 3. You billed 4 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually provided, were correctly coded, and were medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 87801 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87801 billed for date of service November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega3. 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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Kerecis Omega3 is unproven and not medically necessary for any indication, due to 
insufficient evidence of efficacy. There is not enough evidence in the medical literature to show that the 
product has a role in improving outcomes in this scenario. The review has determined that the items/services at issue in this case  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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3 (Q4158).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to S1-S3 (64625, 99152, 
and 99153). 
 
You asked the Plan to pre-approve RFA to S1-S3. 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 follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 to S1-S3. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this is considered experimental therapy 
because the literature reports very variable efficacy. Therefore, the request is considered 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 to S1-S3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) to S1-S3 (64625, 99152, and 99153).
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 the enrollee deserves the best outcome to 
return to their prior level of function.  The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in the current hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving but still is unstable and only requires short-term 
additional acute care at the current facility until they are more appropriate for a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered when specific criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of bracing for fracture. 
More conservative measures are 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says they will continue to cover medically 
necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an 
alternate level of care (such as a skilled nursing facility), or until the clinical circumstances change such that 
LTACH may be reconsidered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 11, 2023. 
 
You asked the Plan to pay for the medical services. You say that you billed this claim with payable diagnosis 
codes. The Plan denied your request. The Plan says you billed this claim with an inappropriate pair of 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of F12.959 and F12.20. Code F12.20 is an Excludes1 code 
under code F12.959, so these two diagnoses cannot be billed together. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not 
been met. Therefore, we decided that the Plan does not have to pay for medical services provided on February 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E/M) service billed with 
code 99214 for date of service January 26, 2023. 
 
You asked the Plan to pay for code 99214. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not bill this code with the required 25 modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider bills a E/M service at the same time 
as a counseling to prevent tobacco use service, the E/M service must have the 25 modifier appended. 
 
In this case, you billed a counseling to prevent tobacco use service at the same time as the E/M service in 
dispute (code 99214).  However, you did not append the 25 modifier as is required by the rules. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99214 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management (E/M) service billed with code 99214 for date of service January 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clopidogrel Bisulfate. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Clopidogrel Bisulfate.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer.  
You asked the Plan to pre-approve Injectafer. You say that the enrollee is not tolerating oral iron enough to 
replenish their iron stores.  The Plan denied your request. The Plan says the step therapy requirements have not 
been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan does not have to pre-approve 
Injectafer.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found that the enrollee has tried and failed the 
require drug Venofer however, there is no reason as to why the enrollee needs Feraheme. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 the enrollee meets the criteria for 
inpatient LTACH care that cannot be accomplished at a lower level of care. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary, and the enrollee can safely receive the care they 
need in their current acute care setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving but still is unstable and only requires short-term 
additional acute care at the current facility until they are more appropriate for a lower level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a SPRINT peripheral nerve stimulation (PNS) device (64555). 
 
You asked the Plan to pre-approve a SPRINT PNS device. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted peripheral nerve stimulators are covered 
when certain criteria are met. 
 
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 SPRINT PNS device. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has a specific 
peripheral neuropathy which is documented on electromyography/nerve conduction velocity (EMG/NCV). The 
request is 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 a SPRINT PNS device have been met. Therefore, we decided that the Plan has 
to pre-approve a SPRINT peripheral nerve stimulation (PNS) device (64555).  
 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.