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

 
We decided that the Plan does not have to pay for add a tooth to existing partial denture (D5650) provided on 
February 6, 2023. 
 
You asked the Plan to pay for the add a tooth to existing partial denture. You say that you were aware that the 
dentist was not participating and full charge would not be covered, but you were expecting some form of the 
bill to be approved. The Plan denied your request. The Plan says this service is not covered by the 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 add a 
tooth to existing partial denture (D5650) provided on February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft for spine surgery. 
 
You asked the Plan to pre-approve allograft. You say that you are appealing with supporting records. 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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Infuse bone morphogenetic protein (BMP) is not Food & Drug Administration (FDA) approved 
for use in the posterior lumbar spine. Iliac crest autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft for spine surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power scooter repairs. 
 
You asked the Plan to pre-approve the power scooter repairs. You say that you disagree with the denial for 
repairs to your power scooter. The Plan denied your request. The Plan says the repair work order is not 
adequate and does not justify all line items being requested. 
 
The Plan follows Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a capped 
rental item may be replaced in cases of loss or irreparable damage. Irreparable wear refers to deterioration 
sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment 
due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. The rules also 
say that the reasonable useful lifetime of equipment, but in no case can it be less than five years. 
 
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 power scooter repairs. Our reviewer 
says that the repairs are not necessary. Our physician reviewer found that the record is unclear that the scooter 
has experienced normal wear and tear. You reference traveling on dirt rural roads. The scooter is for home use 
and the current one under review has extensive damage in less than four years, which is inconsistent with 
normal wear and tear. 
 
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 power scooter repairs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power scooter repairs.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
36 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 65.9 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring non-pneumatic compression device. 
 
You asked the Plan to pre-approve a Koya Dayspring compression device. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this item 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 a Koya Dayspring compression device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that this device is not the standard of care for the enrollee's condition. 
This device has also not been shown to be equal to the standard 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 a Koya Dayspring compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Koya Dayspring non-pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 You asked the Plan to pre-approve Epogen. You say that  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 Epogen. Our reviewer says that Epogen 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the required 
drugs Retacrit or Procrit. Also, the documentation does not support that the Plan's required drugs would likely 
be less effective and or would likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the eye 
doctor staff called the ambulance and you declined the need to go to the hospital. You also say that you should 
not be responsible for the cost of the ambulance since you did not initiate the call or give permission for the 
call. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron (J8597). 
 
You asked the Plan to pre-approve the medication. You say that the drug should be covered. 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 Ondansetron (J8597).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73030, 73060, 73562, 93005, 93041, and 
96372 for date of service February 26, 2023. 
 
You asked the Plan to pay for procedure codes 73030, 73060, 73562, 93005, 93041, and 96372. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly. 
 
 We looked at the file and Medicare rules. Review of the file shows that codes 73030, 73060, 73562, 93005, 
93041, and 96372 have a status indicator of Q1. Code 99285 was billed on the same date of service with a 
revenue code of 450, which has a status indicator of "V". Therefore, codes 73030, 73060, 73562, 93005, 
93041, and 96372 which have a status indicator of Q1, are not separately payable. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 73030, 73060, 73562, 93005, 93041, and 
96372 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 73030, 
73060, 73562, 93005, 93041, and 96372 for date of service February 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 14, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $55 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/ultrasound 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 does not have to waive the copayment for an 
ultrasound provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), 
pontic - porcelain fused to high noble metal (D6240), and retainer crown - porcelain/ceramic (D6740) provided 
on February 20, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D2950, D6240 and D6740. You say that 
you have never had a supplemental policy and are asking for attention to straighten out this claim. The Plan 
denied your request. The Plan says your benefit for the requested services $1,500 dollar limit was met 
 
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 services was exhausted on dates of service February 15, 2023, and 
February 20, 2023. Therefore, we decided that the Plan does not have to pay for core buildup, including any 
pins when required (D2950), pontic - porcelain fused to high noble metal (D6240), and retainer crown - 
porcelain/ceramic (D6740) provided on February 20, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99284 billed for date of service December 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim is not a duplicate. The Plan denied 
your request. The Plan says that only one evaluation and management service may be reported. 
 
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 file does not include an additional claim, explanation of benefits, or any other documentation to show that 
an additional evaluation and management services was provided. The Plan has not provided insufficient 
information to show that the code is not eligible for payment in this case. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for procedure code 99284 billed for date of service December 
25, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
8, 2023. 
 You asked the Plan to pre-approve SNF care after June 8, 2023. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after June 8, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after June 8, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 8, 2023.
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 will require extensive 
rehabilitative therapies to regain strength and functional quality of life. The Plan denied your request. The Plan 
says the enrollee does not meet the requirements for admission to an LTACH.  
 
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 there is no documentation provided indicating a medical necessity for admission 
to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an 
inpatient basis. 
 
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 L1 and L3 Kyphoplasty (22514, 22515).  
 
You asked the Plan to pre-approve L1 and L3 Kyphoplasty. You say that you are in pain and cannot walk or 
sleep well. The Plan denied your request. The Plan says in this case, medical necessity coverage criteria are not 
met for surgical intervention given the lack of advanced imaging.  
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty is covered when the criteria in the rules 
section of this letter 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 L1 and L3 Kyphoplasty. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that detailed documentation is 
not evident regarding worsening pain. There is no indication of a progression of the body height loss, greater 
than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there 
is no magnetic resonance imaging (MRI) provided. Therefore, you do not meet 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 L1 and L3 Kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L3 Kyphoplasty (22514, 22515).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Gel-One is only covered for certain indications. 
 
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 Gel-One. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of osteoarthritis of the knees. the enrollee had worsening knee pain 
after the viscosupplementation injection with Synvisc-One on February 13, 2023. The review has determined 
that the enrollee does not meet criteria for the requested Gel One injection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.