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

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 8, 13, and 14 and retainer 
crowns (D6740) for tooth #'s 9, 12, and 15. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services 
approved because the procedures rendered in December were temporary, and need to change the units for 
permanent units. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows one pontic (D6245) and three retainer crowns (D6740) were pre-approved on April 3, 2023, and April 
21, 2023, and your pontics and retainer crowns benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve pontics (D6245) for tooth #'s 8, 13, and 14 and retainer crowns (D6740) for tooth 
#'s 9, 12, and 15.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care management services provided on December 28, 2022. 
 
You asked the Plan to pay for care management services. You say that the enrollee could not choose a different 
provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for care management 
services provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6209 for date of service January 5, 2023. 
 
You asked the Plan to pay for code A6209. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the items rendered are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for code A6209 billed without A1-A9 
modifiers will be rejected as missing information. 
 
We looked at the file and Medicare rules. Review of the file shows that code A6209 was not billed with a A1-
A9 modifier. Based on this information, we decided that Medicare rules for coverage of code A6209 have not 
been met. Therefore, we decided that the Plan does not have to pay for code A6209 for date of service January 
5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drug, 
zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of skin substitute grafts (15271, 15275, 
Q4173, and Q4210). 
 
You asked the Plan to pre-approve application of skin substitute grafts. You say that the requested application 
of skin substitute grafts is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested application of skin substitute grafts. 
 
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 application of skin substitute grafts. 
Our reviewer says that the enrollee does not meet criteria for the requested application of skin substitute grafts. 
Our physician reviewer found the medical documentation establishes that between March 27, 2023, through 
May 16, 2023, this enrollees ulceration has reduced in size. On March 27, 2023, the ulceration measured 4 cm 
x 2.6 cm x 0.1 cm. As of May 15, 2023, the ulceration reduced in size to 2.8 cm x 2.5 cm x 0.1 cm. The 
enrollee has been receiving wound debridement, wound dressings, and offloading of the ulcer site. LCD 
guidelines advise that application of a skin substitute graft for lower extremity diabetic foot ulcerations will be 
covered when the following conditions are met and documented as appropriate for the individual patient: presence of a neuropathic diabetic foot ulcer having failed to respond to documented conservative wound care 
measures of greater than four weeks. After four weeks, the medical documentation supports that this enrollees 
ulceration has reduced in size. Therefore, the requested skin substitutes are not medically reasonable or 
necessary for this enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of application of skin substitute grafts have not been met. Therefore, we decided 
that the Plan does not have to pre-approve application of skin substitute grafts (15271, 15275, Q4173, and 
Q4210).
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. The Plan denied your request. The Plan says the enrollee does not 
require daily medical management of complex/active medical conditions that cannot be addressed at 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 enrollee has hemiparesis, partial blindness related to cerebrovascular accident and 
was admitted to the acute care hospital with viral pneumonia complicated by acute renal injury. Physical 
therapy was recommended. Our reviewer found that however, the enrollee is stable without complex 
rehabilitation needs and does not require ongoing inpatient care for rehabilitation. Our physician reviewer 
found that although the enrollee appears to be able to participate in an intensive therapy program, the enrollee 
does not require 15 hours of rehabilitation per week in an IRF, based on the provided documentation. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Renflexis (Q5104). 
 You asked the Plan to pre-approve Renflexis. You say that Renflexis is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Renflexis have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Renflexis. Our reviewer says that 
Renflexis is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Remicade, Inflectra, infliximab or Simponi Aria, and Stelara, before they will approve 
the requested drug, Renflexis. There is no indication that the enrollee has tried and failed the required drugs. 
Based on the medical records provided and the Medicare-approved major drug compendia, there is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Renflexis (Q5104).
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 the services that the enrollee needs can be provided safely in another setting 
such as a skilled nursing facility or home with home health services. 
 
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 cannot use a leg prosthesis. The enrollee cannot participate in intensive 
rehabilitation and does not require frequent physiatry oversight. IRF criteria 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic 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 medical studies have not proven that this item is helpful for treatment. 
 
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 the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's brachial plexus condition or in widespread use for this patient's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
Intracept procedure. 
 
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 Intracept procedure. Our reviewer 
says that the enrollee does not meet criteria for the Intracept procedure. Our physician reviewer found the 
records do not contain a magnetic resonance imaging (MRI) that shows modic endplate changes without 
foraminal stenosis or facet degenerative 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.  
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the member needs to 
have the procedure done to correct her posture. The Plan denied your request. The Plan says the requested 
percutaneous vertebral augmentation does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that percutaneous vertebral augmentation is not considered medically necessary in this case. 
Our physician reviewer found that the Medicare LCD limits this procedure to acute (<6 weeks) or subacute  
(6-12 weeks) osteoporotic Vertebral Compression Fracture (T1- L5), based on symptom onset. This event 
occurred in 2021 and therefore does not meet the criteria. The request is deemed not 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 you need the rehab to get better. The Plan denied 
your request. The Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 you want to return to your prior level of function and 
believe that this would be the level of care you need. The Plan denied your request. The Plan says the services 
you need can be provided safely in another setting such as a skilled nursing facility, home with home health 
services, or home with outpatient therapy. 
 
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 you do not have complex or intensive rehabilitation needs. You do not require 
intensive or complex rehabilitation services. IRF criteria 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for September 17, 2022, to 
September 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99221 is 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 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99221 is not supported in the medical record. Specifically, the records show that the 
enrollee was previously seen and there is a more appropriate code for the services. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99221 billed for September 17, 2022, to September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88365 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure code 88365. You say that this is a payable code The Plan denied your 
request. The Plan says payment for code 88365 is bundled into payment for code 88377. 
 
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, we have confirmed that code 88365 
is a column II code to column I code 88377. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88365 billed for date of service December 20, 
2022.