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

 
We decided that the Plan does not have to pay more for prophylaxis, adult (D1110) and periodic oral evaluation 
(D0120) provided on April 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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. 
 
You have been 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 prophylaxis, adult (D1110) and periodic oral 
evaluation (D0120) provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 6, 
2023. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The claim shows that the services were provided in an ambulatory surgical 
center. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the 
home. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device provided on March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc NP allograft at L5-S1. 
 
You asked the Plan to pre-approve a Via Disc NP allograft. You say that this procedure is needed to 
supplement the enrollee's nucleus pulposus tissue loss resulting from disc degeneration in order to reinforce the 
cushioning function. The Plan denied your request. The Plan says medical reports have failed to show that this 
procedure is effective. 
 
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 Via Disc NP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found via disc NP allograft is experimental for back pain. 
 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 Via Disc NP allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via Disc NP allograft at L5-S1.
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 medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
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 criteria for coverage. Our physician reviewer found there is no trial of fracture 
bracing. 
 
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).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix skin substitute (Q4186). 
 
You asked the Plan to pre-approve Epifix skin substitute. You say that this is medically necessary. 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 Epifix skin substitute. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have record showing that the wound is indeed a chronic and 
non-healing associated with diabetes or abnormal vascularization. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Epifix skin substitute (Q4186).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-
minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the enrollee may lose a toe due to 
an infection. She needs this therapy to save her toe. The Plan denied your request. The Plan says that the 
records do not show that you have a diagnosis of non-healing diabetic foot wound which has failed standard 
wound care over 30 days given the lack of wound measurements in the setting of assessment and correction of 
any vascular compromise. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found after careful review of the enclosed information and the pertinent guidelines for 
this case, it is my opinion that the enrollee does meet the Medicare criteria for HBOT. It is my opinion that the 
requested hyperbaric oxygen therapy is medically reasonable and necessary. The medical documentation 
supports that this enrollee is suffering with a wet gangrene diabetic ulceration third digit right side. 
Osteomyelitis has been confirmed both on MRI and three phase bone scans. The enrollee demonstrates a 
nonhealing diabetic wound which meets the Medicare criteria for hyperbaric oxygen therapy. The ulceration has increased in size over the past 30 days and has been recalcitrant to wound debridement and dressings. It is 
my opinion that this enrollees grade 4 diabetic ulceration third digit right side with underlying osteomyelitis 
meets the coverage criteria for hyperbaric oxygen therapy. Therefore, it is my opinion that the requested 
hyperbaric oxygen therapy is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have been met. Therefore, we decided that the Plan 
has to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).  
 
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: 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that the services you 
require can only be given in a hospital setting. When ready to leave the hospital, services needed may be 
provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of the intraosseous basivertebral. 
 
You asked the Plan to pre-approve a thermal destruction procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure has been correctly denied. 
 
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 thermal destruction procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the magnetic resonance imaging (MRI) shows disc hernaitions and facet 
joint disease. The cause of back pain is not clear. 
 
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 thermal destruction procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a thermal destruction of the intraosseous basivertebral.
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's needs cannot be adequately 
cared for in their current condition at a skilled nursing facility or any other lower level of care as they require 
prolonged hospitalization and close physician monitoring. You would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the acute hospital can provide for all the enrollees present inpatient care needs 
and the Plan has stated that continued care in the short-term acute hospital will be covered as is medically indicated. The enrollee is presently receiving appropriate services in the acute care setting. Records do not 
support the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital 
is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
(E0601) and humidifier (E0652). 
 
You asked the Plan to pre-approve the CPAP and humidifier. You say that the items should be covered. The 
Plan denied your request. The Plan says there is no evidence of adherence to PAP therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP 
greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime 
during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP and humidifier have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the continuous positive airway pressure (CPAP) device (E0601) and humidifier (E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T9, T10, and T12 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T9, T10, and T12 kyphoplasty. You say that this is medically necessary. 
The Plan denied your request. The Plan says medical necessity coverage criteria is not met as the pain is 
multifactorial with multilevel disc disease in the thoraco-lumbar spine. 
 
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 T9, T10, and T12 kyphoplasty. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found 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 magnetic resonance imaging corroboration of plausible other causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T9, T10, and T12 kyphoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve T9, T10, and T12 kyphoplasty (22513, 22515).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on November 16, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed services 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. 
 
We find that the billed outpatient services are not supported in the medical record. Specifically, payment for 
these services is included in payment for the related inpatient admission. Based on this information, we decided 
that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient services provided on November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy. 
 
You asked the Plan to pre-approve a percutaneous laminotomy. You say that this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says this procedure has been correctly denied. 
 
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 percutaneous laminotomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental. 
 
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 percutaneous laminotomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous laminotomy.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says  the enrollee does not meet the requirements. Based on the 
records, services needed may be provided safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing billed for date of service April 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test was medically necessary. The Plan 
denied your request. The Plan says that the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does show that the required unique identifier 
was reported. 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 the Guardant360 testing billed for date of 
service April 27, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet 
joint nerve 
 You asked the Plan to pre-approve destruction by neurolytic agent. You say that the enrollee has chronic lower 
back pain. The Plan denied your request. The Plan says this procedure 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 destruction by neurolytic agent. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has already had two of these procedures done. There is not 
enough information provided to verify an additional procedure is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet joint nerve