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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz is required before alternatives can be considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guardhard appliance, full arch (D9944) 
provided on November 9, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered 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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard
hard appliance, full arch (D9944) provided on November 9, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services billed with Patient- Driven Groupings Model 
(PDGM) 2EB11 for date of service July 1, 2021, to July 16, 2021. 
 
You asked the Plan to pay for home health services billed with PDGM 2EB11. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says that PDGM 1EB11 is more appropriate. 
 
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 asked our coder 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 home health services billed with PDGM 2EB11. Our 
reviewer says that the documentation supports the PDGM billed. Our reviewer found the enrollee was admitted 
to home care within 14 days of an acute hospital stay secondary to a broken knee prosthesis. The record 
indicates the enrollee was referred from an acute hospital. The record indicates the enrollee was referred from 
an acute hospital to address continuing care needs following an acute treatment in the hospital. The plan has not 
provided information to the contrary. Therefore, the provider coded properly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services billed with PDGM 2EB11 have been met. Therefore, we 
decided that the Plan has to pay for home health services billed with Patient- Driven Groupings Model 
(PDGM) 2EB11 for date of service July 1, 2021, to July 16, 2021.  
 
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 gingivectomy or gingivoplasty (D4212). 
 
You asked the Plan to pre-approve gingivectomy or gingivoplasty (D4212). You say that you are requesting 
reconsideration for the denial of dental code D4212. The Plan denied your request. The Plan says the service 
is not eligible for coverage under the medical benefit and is a non-covered code under the dental benefit. 
 
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 items or services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingivectomy or gingivoplasty (D4212).
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 June 24, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
declined the transportation because you were experiencing syncope, but after 30 minutes you began to feel 
better. 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 June 24, 2022. 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 June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service October 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43273 for date of service May 23, 2022. 
 
You asked the Plan to pay for procedure code 43273. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 43273 is endoscopic cannulation of papilla with direct 
visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure). 
 
We find that CPT code 43273 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an endoscopic cannulation of papilla with direct visualization of pancreatic/common 
bile duct(s); therefore, code 43273 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of procedure code 43273 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 43273 for date of service May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided from 
January 10, 2023, to February 21, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have been seeing this provider for 
years. You say they have helped you beyond measure. You also say that you do not want to start over with a 
new counselor. The Plan denied your request. The Plan says the provider in this case is not eligible to 
participate in Medicare. The Plan also says that payment cannot be made for services performed by a provider 
that is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) 
provided from January 10, 2023, to February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - two surfaces, posterior 
(D2392) provided on February 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware of a deductible; you 
thought you only had a 20% coinsurance. You would like to be reimbursed for the deductible and coinsurance. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
  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. Enrollees must pay $100 
deductible and 20% coinsurance for covered in and out-of-network dental services and may be billed by the 
out-of-network provider for any charged amount greater than the payment made by the Plan. 
 
You have been asked to pay $104.32, which is 20% of the allowed amount for resin-based composite - two 
surfaces, posterior (D2392) and $100 deductible. The allowed amount is $121.62 (20% x $121.62 = $4.32 + 
$100 deductible = $104.32). 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
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 pay more for resin-based composite - two surfaces, posterior (D2392) 
provided on February 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute rehab facility can help the enrollee be at 
home alone without assistance. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met in another 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral exam provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 21, 2022, and July 22, 2022. Therefore, we decided that the Plan does not have to pay for periodic oral exam provided on 
November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot inserts (L3000) provided on November 22, 2022. 
 
You asked the Plan to pay for the foot inserts. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided in this case. The delivery receipt is not itemized and does not show what specifically was delivered. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for foot inserts (L3000) provided on November 22, 2022.
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 October 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was dispatched to your home due to you having trouble breathing. You also say that you felt more 
comfortable for your daughter to transport you. 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 October 17, 2022. 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 October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU) (55880). 
 
You asked the Plan to pre-approve HIFU. You say that this service is recognized and a reasonable treatment 
option for the enrollee's condition. You also say that this procedure would lessen the enrollee's recovery time. 
The Plan denied your request. The Plan says that the requested service is not medically necessary for initial 
treatment for the enrollee's condition. 
 
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 HIFU. Our reviewer says that the 
requested HIFU is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested service is appropriate and indicated for the enrollee's condition. The reviewer also found 
that this service is approved by the Food and Drug Administration for the enrollee's condition. Therefore, the 
reviewer found that the requested HIFU is medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have not been met. Therefore, we decided that the Plan has to pre-
approve high intensity focused ultrasound (HIFU) (55880).  
 
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 a Group 3 power wheelchair with multiple power 
options and accessories, including an attendant control. 
 
You asked the Plan to pre-approve an attendant control. You say that the requested power wheelchair is 
medically necessary for the enrollee. The Plan denied your request. The Plan says an attendant control cannot 
be covered in addition to a beneficiary-operated joystick. 
 
The Plan follows Medicare rules. Medicare rules say that an attendant control is covered in place of a 
beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable 
to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but 
is able to operate a power wheelchair.  
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 attendant control. Our reviewer says 
that an attendant control is not medically necessary. Our physician reviewer found the provided documentation 
indicate that the enrollee has adequate upper extremity strength to manage standard power drive controls. The 
documentation does not support that that the enrollee requires an attendant control. Therefore, the reviewer 
found that the requested attendant control 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 an attendant control have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair with multiple power options and accessories, 
including an attendant control.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 for date of service September 21, 
2022. 
 
You asked the Plan to pay for procedure code 64494. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 64494 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). 
 
We find that CPT code 64494 is not supported in the medical record. Specifically, this code has a payment 
indicator of N. This means that payment is packaged into payment for other services. No separate payment can 
be made. Based on this information, we decided that Medicare rules for coverage of procedure code 64494 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 64494 for date 
of service September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assistance device. 
 
You asked the Plan to pre-approve a respiratory assistance device. You say that the enrollee's current CPAP 
mask was leaking with no other issues reported. The Plan denied your request. The Plan says there must be 
current supporting clinical information that demonstrate that the enrollee's current device is unrepairable. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee currently has a CPAP device. The coverage guidelines state that there must be 
current supporting clinical information that show the current device is unrepairable. The records show that 
there is no current documentation that shows the enrollee's current device needs repairs. The records also show 
that the requested supplies were approved by the Plan. A continuous positive airway pressure (CPAP) device 
serves the same purpose as a respiratory assistance device. Therefore, we decided that the Plan does not have to 
pre-approve a respiratory assistance device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MRI of the upper extremity joint. 
 
You asked the Plan to pre-approve an MRI of the upper extremity joint. You say that you are in too much pain 
to go through physical therapy and would like to see if an MRI would be covered without therapy. The Plan 
denied your request. The Plan says an MRI of the upper extremity joint is not medically necessary. 
 
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 an MRI of the upper extremity joint. 
Our reviewer says that the MRI of the upper extremity joint is not medically necessary. Our physician reviewer 
found that you have left shoulder and neck pain. However, the detailed documentation regarding a trial and 
failure of a recent, reasonable, comprehensive, less invasive, conservative care measures is not evident. The 
peer reviewed literature supports the trial and failure of conservative measures prior to proceeding with 
imaging. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
diagnostic study in this clinical setting. There is also no compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
left shoulder MRI of the upper extremity joint 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 an MRI of the upper extremity joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI of the upper extremity joint.