Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tepezza. 
 
You asked the Plan to pre-approve Tepezza. You say that the requested Tepezza is medically necessary. The 
Plan denied your request. The Plan says that the requested Tepezza is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Tepezza. Our reviewer says that the 
requested Tepezza is medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of thyroid eye disease. The record indicates that the enrollee has a hemoglobin HgA1c of 6.6. 
The Food and Drug Administration (FDA) has stated that the requested drug is indicated for approval by the 
FDA as the originator biological product for the treatment of thyroid eye disease, regardless of disease activity 
or duration. The elements of the coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have been met. Therefore, we decided that the Plan has to pre-approve 
Tepezza.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crown  further treatment or completion of 
diagnosis necessary prior to final impression (D2799) Tooth #3 and 6 and clinical crown lengthening  hard 
tissue (D4249) Tooth #6. 
 
You asked the Plan to pre-approve dental services. You say that the denied services are covered under the 
enrollee's Plan. The Plan denied your request. The Plan says the service is not covered under your 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. Interim crown  further 
treatment or completion of diagnosis necessary prior to final impression (D2799) and clinical crown 
lengthening  hard tissue (D4249) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2799 and D4249 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
interim crown  further treatment or completion of diagnosis necessary prior to final impression (D2799) Tooth 
#3 and 6 and clinical crown lengthening  hard tissue (D4249) Tooth #6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on October 3, 2022. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not eligible to 
be paid for assistant at surgery services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on October 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the requested test was ordered to provide 
additional assistance in either diagnosing or determining a course of action regarding frontotemporal dementia 
and Alzheimer's disease. The Plan denied your request. The Plan says a PET scan if not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found that while the records indicate you have 
aphasia, there is no indication that the exam is being requested in the context of a clinical trial. There is no 
indication that you meet the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia. 
Therefore, the elements of coverage criteria are not satisfied, and the requested service is not recommended. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain/ceramic crown provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered in full. The Plan denied 
your request. The Plan says your $1,000 yearly allowance has 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 November 29, 2022. 
Therefore, we decided that the Plan does not have to pay for porcelain/ceramic crown provided on November 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on June 10, 2022. 
 
You asked the Plan to pay for the panel testing. 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. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 4, 2022, to 
February 13, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis code was based on the provider's diagnostic statement. The Plan denied your request. The Plan says 
there was insufficient evidence to validate the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E44.0, defined as moderate protein-calorie 
malnutrition. 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 pay for the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that in the emergency department, the enrollee was noted 
to be in no acute distress and was described as well nourished. The documentation stated that the enrollee 
denied weight loss and had a body mass index of 26.3. While the provider acknowledged the diagnosis of 
moderate malnutrition, the medical record found no evidence of clinical symptoms or findings consistent with 
malnutrition. The review has determined that the documentation did not support diagnosis code E44.0.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 4, 2022, to February 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table tray. 
 
You asked the Plan to pre-approve an over-bed table tray. You say that the item would help with eating and 
washing. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table tray.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee can safely receive the services needed 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6219 billed for date of service December 2, 
2022. 
 
You asked the Plan to pay for procedure code A6219. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A6219 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6219 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6219 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6219 billed for date of service December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
spacer at L3-4 and L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes A6219 and A6222 billed for date of service December 
5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records prove medical necessity. 
The Plan denied your request. The Plan says that the services are bundled into payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT codes A6219 and A6222 are payable under the durable medical equipment fee schedule. The 
national provider identifier (NPI) information shows that the provider is a durable medical equipment supplier. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure codes A6219 and A6222 billed for date of service 
December 5, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ForeseeHome eye monitoring device (0379T). 
 
You asked the Plan to pre-approve a ForeseeHome eye monitoring device. You say that the ForeseeHome is 
Food and Drug Administration (FDA) approved and has been covered by Medicare since 2015. The Plan 
denied your request. The Plan says this service is not covered under Medicare. 
 
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 ForeseeHome eye monitoring device. 
Our reviewer says that a ForeseeHome eye monitoring device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not show that this device is not mainly for 
the convenience of the patient or the physician. The ForeseeHome eye monitoring device is experimental or 
investigational. Our reviewer found that this device is not being furnished in accordance with accepted 
standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the 
function of a malformed body member. The treating Provider has recommended the available medical 
appropriate alternative of Amsler Grid home testing, and there is no documentation that the patient is unable to 
perform the appropriate alternative. Our physician reviewer also found that therefore, the criteria for medically 
reasonable and necessary is 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 a ForeseeHome eye monitoring device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a ForeseeHome eye monitoring device (0379T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body (D6010), 
abutment supported porcelain crown (D6058), custom fabricated abutment (D6057) and surgical access to an 
implant body (D6011). 
 
You asked the Plan to pre-approve dental implants and crowns. You say that this should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 pre-approve 
surgical placement of an implant body (D6010), abutment supported porcelain crown (D6058), custom 
fabricated abutment (D6057) and surgical access to an implant body (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post core (D2954) provided on December 21, 
2022. 
 
You asked the Plan to pay for prefabricated post core. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 
prefabricated post core (D2954) provided on December 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic polysomnogram (95810) 
 
You asked the Plan to pre-approve a diagnostic polysomnogram. The Plan denied your request. The Plan says 
this request is not medically necessary because you have a valid sleep study with appropriate titration settings 
which can be used for re-implementation of a continuous positive airway pressure (CPAP) machine. 
 
The Plan follows Medicare rules. Medicare rules say that repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. 
 
 
 
 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 diagnostic polysomnogram. Our 
reviewer says that a diagnostic polysomnogram (95810) is not medically necessary. Our physician reviewer 
found that you have known obstructive sleep apnea and had been on bilevel positive airway pressure (BiPAP) 
in the past, but you have not used the device in more than a year. You now wish to start using the device. Our 
reviewer found that the medical notes indicate that a "split study requested". However, the actual order is for a 
diagnostic sleep study. Our physician reviewer found it would be reasonable to restart BiPAP at the settings 
previously determined at your original titration study. Effectiveness of treatment can then be determined with 
device downloads. Our reviewer also found that a repeat diagnostic sleep study is not needed because your 
diagnosis is known. 
 
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 diagnostic polysomnogram have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a diagnostic polysomnogram (95810)