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

 
We decided that the Plan does not have to pre-approve an interim crown  further treatment or completion of 
diagnosis necessary prior to final impression (D2799). 
 
You asked the Plan to pre-approve the interim crown. The Plan denied your request. The Plan says this service 
is not covered in your dental benefit. 
 
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 interim crown is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim crown 
 further treatment or completion of diagnosis necessary prior to final impression (D2799).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62143 provided on October 4, 2022. 
 
You asked the Plan to pay for procedure code 62143. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code 62143 is included in the global surgery 
payment for procedure code 62143 provided on September 16, 2022. Separate payment cannot be made for 
procedure code 62143. Based on this information, we decided that Medicare rules for coverage of procedure 
code 62143 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
62143 provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the panoramic 
radiographic image (D0330) provided on February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider could not find your previous x-rays 
so they did them again and you objected to the procedure because it was not necessary. The Plan denied your 
request. The Plan says your benefit for the requested items or services 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 the Plan paid for a comprehensive oral evaluation (D0150) and a complete series of radiographic images 
(D0210) on February 14, 2023; therefore, your benefit for the requested items or services was exhausted on the 
date of service of February 14, 2023. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) and the panoramic radiographic image (D0330) provided on February 
23, 2023.
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 admission to an IRF is not medically necessary.  
 
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 the enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-contrast computed tomography (CT) of the heart 
with calcium scoring (75571) 
 
You asked the Plan to pre-approve a computed tomography (CT). The Plan denied your request. The Plan says  
Medicare does not cover the requested study for screening purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a computed tomography (CT). Our 
reviewer says that there is insufficient support in the peer-reviewed literature demonstrating a significant 
benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal 
management of this patient. This service is considered experimental/investigational for the evaluation and 
management of this enrollee's medical condition. Our physician reviewer found  
 
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 computed tomography (CT) have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-contrast computed tomography (CT) of the heart with calcium scoring 
(75571)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that without the patch your 
levels will get out of control, and you will end up on insulin. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the additional information from your physician indicates 
that you do not use insulin or have a history of problematic hypoglycemia. Based on this information, we 
decided that Medicare rules for coverage of the supply allowance for the CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal, and 
contents (72148). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. You say that a MRI is medically for the 
enrollee. The Plan denied your request. The Plan says that records do not show documentation of physical 
exam results that included a detailed nervous system (a network of nerve cells and fibers that send nerve 
messages between parts of your body) performed after symptoms started or changed that support imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a Magnetic resonance imaging. Our 
reviewer says that you need this medical item. Our physician reviewer found medical necessity of the requested 
MRI has been demonstrated in the fact that the enrollee is seeking neurosurgical opinion for increasing 
symptoms and last MRI of 2020 was incomplete. For neurosurgical consultation to occur in an enrollee with 
prior lumbar surgery a current, up to date MRI will be 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 Magnetic resonance imaging have been met. Therefore, we decided that the 
Plan has to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal, and contents (72148).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3010) and (L3410).  
 
You asked the Plan to pre-approve foot orthotics. You say that you have a discrepancy in your leg length, some 
metatarsal degeneration in your toe and are unable to walk comfortably. You also say that you no longer wear 
braces therefore you need to be able to switch which shoes you wear. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010) and 
(L3410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 18) provided on February 
28, 2023. 
 
You asked the Plan to pay for the dental services. You say that these procedures should be considered simple 
extractions and covered by the Plan. The Plan denied your request. The Plan says this service is not a covered 
benefit 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 
surgical extractions (D7210 x 18) provided on February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs, self-administered. 
 
You asked the Plan to pre-approve the drugs, self-administered. You say that this drug was prescribed for pain 
control. 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 the drugs, self-
administered.  
 
Benefits for the drugs, self-administered 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 22, 2023. 
 
You asked the Plan to pay for the medication. You say that you went to the emergency room for chest pain. 
Any medication you were given was done to save your life. 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 pay for self-administered drugs provided 
on February 22, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000 x 2) provided on March 21, 2023.  
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of Plan's denial for 
payment. The Plan denied your request. The Plan says these items are not a covered benefit for the enrollee's 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for the foot 
orthotics (L3000 x 2) provided on March 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended sleep study (95806). 
 
You asked the Plan to pre-approve an unattended sleep study. You say that you would like to be allowed to get 
a sleep study for the diagnosis of sleep apnea. The Plan denied your request. The Plan says there is no 
explanation given for the use of an out-of-network provider, and no response to the suggested use of a network 
provider is noted. The Plan also says that the repeat study is not explained as to medical necessity given prior to 
diagnosis and no change in weight or medical conditions. 
 
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 an unattended sleep study. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you already have a diagnosis of obstructive sleep apnea (OSA), treated 
with continuous positive airway pressure (CPAP). You were seen for an annual health visit on May 23, 2023. 
Our reviewer found that it is noted the Epworth score was 12, but the clinical notes do not indicate whether you 
were using CPAP.  There was no device download data. Our physician reviewer also found that since you 
already have a diagnosis of OSA, the requested diagnostic home sleep study is not 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 unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an unattended sleep study (95806).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and each additional radiographic image (D0230) provided on April 11, 2023. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image and each additional 
radiographic image. The Plan denied your request. The Plan says your benefit for the  intraoral - periapical first 
radiographic image and each additional radiographic image 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 intraoral - periapical first radiographic image and each additional radiographic 
image was exhausted on date of service April 11, 2023. The Plan paid for one of the additional radiographic 
images D0230 which exhausted this benefit. 
 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), and each additional radiographic image (D0230) provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination and evaluation 
(92012) provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination and evaluation (92012). You say 
that you are appealing with supporting records. 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 $40 
copayment for medical eye exam. 
 
You have been asked to pay a $40 copayment for a medical eye examination and evaluation (92012). This 
item/service falls within the medical eye exam 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 a medical eye examination and evaluation (92012) provided on April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 and MPL genetic testing. 
 You asked the Plan to pre-approve JAK2 and MPL tests. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet the criteria for these tests. 
 
The Plan follows Medicare rules. Medicare rules state that JAK2 and MPL tests may be covered if 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 JAK2 and MPL tests. Our reviewer 
says that the enrollee does not meet criteria for these tests. Our physician reviewer found the records do not 
document that the enrollee would meet World Health Organization (WHO) diagnostic criteria for 
myeloproliferative disease (MPD) if JAK2 V617F were identified, MPD if a clonal marker were identified, or 
PV if Jak2 exon 12 testing were positive as required by the Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JAK2 and MPL tests have not been met. Therefore, we decided that the Plan 
does not have to pre-approve JAK2 and MPL genetic testing.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 2 home health skilled nursing visits 
(G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the home 
health skilled nursing documentation indicates that you are completing your own wound care and there are no 
signs of infection. You continue to improve your strength and have had education with regards to medication 
management and health behavior adjustments. There is no current need for skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 2 home health skilled nursing visits (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of 25% vertebral body height reduction to L1. There is 
retropulsion noted. There is also additional pathology noted on the magnetic resonance imaging (MRI): a right 
sacral insufficiency fracture; questionable edema involving the bilateral T11 pedicles and T10 and T11 spinous 
processes. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic 
deformity, or a severe impact on the enrollee's daily activities. Moreover, there is MRI corroboration of 
retropulsion. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).