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

 
We decided that the Plan does not have to pre-approve T12 and L1 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T12 and L1 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no magnetic resonance imaging documentation of 25% vertebral 
body height reduction to L1. There is retropulsion noted at T12. 
 
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 T12 and L1 kyphoplasty. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is 
not evident regarding worsening pain. There is no indication of a progression of the body height loss or greater 
than 25% vertebral body height loss at the L1 vertebra. Moreover, there is magnetic resonance imaging 
corroboration of retropulsion at T12 as well as other plausible causes of 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 T12 and L1 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T12 and L1 kyphoplasty (22513, 22515).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites - one surface, anterior (D2330 
x3), and one surface, posterior (D2391 x4). 
 
You asked the Plan to pre-approve the resin-based composites - one surface anterior D2330 x5 and one surface, 
posterior D2391 x4. You say that the fillings the enrollee had five years ago have failed and need to have them 
redone. The Plan denied your request. The Plan says your benefit for the resin-based composites - one surface 
anterior, and one surface posterior 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 your benefit for the resin-based composites - one surface anterior, and one surface, posterior was 
exhausted on the appealed claim. The Plan agreed to pre-approve 2 fillings. Therefore, we decided that the Plan 
does not have to pre-approve resin-based composites - one surface, anterior (D2330 x3), and one surface, 
posterior (D2391 x4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second level of kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says a second level of kyphoplasty cannot be approved when the request is 
only for a single kyphoplasty at level L2. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty may be covered for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this kyphoplasty. 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a second level of kyphoplasty surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided 
October 1, 2022, to November 29, 2022. 
 
You asked the Plan to pay for an acute inpatient psychiatric hospitalization. You say that the full length of stay 
was medically necessary for the enrollee. The Plan denied your request. The Plan says records do not show that 
as of November 14, 2022, enrollee was displaying major disability leading to dangerous or a life-threatening 
functioning because the enrollee's condition had stabilized, and a lower level of care was felt to be appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric 
hospitalization. Our reviewer says that this admission was not medically necessary. Our physician reviewer 
found the records provided for the admission of this patient does not meet the criteria for November 14, 2022, 
forward as this enrollee was not shown to be a danger to herself or others, delusions, auditory or visual 
hallucinations noted. 
 
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 acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for an acute inpatient psychiatric hospitalization provided October 1, 
2022, to November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), a harness 
(E2313), and an expandable controller (E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that when three or more power seating 
functions/actuators/motors are provided the upgraded electronics are allowed. The Plan denied your request. 
The Plan says the requested items are 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection device (E2311), a harness (E2313), and an expandable 
controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T10 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 T10 kyphoplasty. Our reviewer says 
that the enrollee does not meet coverage criteria. 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 T10 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T10 kyphoplasty (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L4 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria for the L4 kyphoplasty is not met given 
documentation of having the absolute and relative contraindications of primary cause of back pain due to 
lumbar stenosis and spondylolisthesis with herniated disc with moderate to severe stenosis and nerve 
compression. 
 
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 L4 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 the enrollee's daily activities. 
Moreover, there is magnetic resonance imaging corroboration of plausible other causes of pain at the requested 
level. In fact, the enrollee has been approved for an L3-4 discectomy and posterior fusion with inpatient 
admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty (22514).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
8, 2022, to December 4, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  The file shows that the enrollee received 100 days of SNF care during the benefit period from August 3, 2022, 
to December 15, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 8, 2022, to 
December 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination (92082) provided on March 24, 
2023. 
 
You asked the Plan to pay for a visual field examination (92082). You say that the denial letter does not fully 
explain why the Plan is denying payment. The Plan denied your request. The Plan says the visual field 
examination (92082) is not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover a visual field examination (92082).  
 
We looked at the file and the Plan's rules. The Plan contract also says that a routine eye examination is covered 
by an optical provider once a year. A visual field examination (92082) is excluded from this benefit. The Plan 
contract also says that any service not specifically listed in the coverage information is not covered. Based on 
this information, we decided that the Plan's rules for coverage of a visual field examination (92082) have not 
been met. Therefore, we decided that the Plan does not have to pay for a visual field examination (92082) 
provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits provided from January 26, 
2023, to February 9, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that your cataract lenses became 
clouded after a few years and needed further surgery. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Medicare-covered vision services at an in-network specialist's office.  
 
You have been asked to pay a $30 copayment for the office visit on each date of service. The office visits fall 
within the vision care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cataract 
laser surgery and the office visits provided from January 26, 2023, to February 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no magnetic resonance imaging (MRI) documentation of 25% vertebral 
body height reduction to L2. There is also disc protrusion, and degenerative changes noted on the MRI. 
 
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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet coverage criteria. Our physician reviewer found there is no documentation of a back 
brace for fracture treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) Tooth #20, 21, 22, 23, 26, 27 and 28. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested services because the provider is in-network. 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. This benefit includes the 
requested extraction, erupted tooth or exposed root (elevation and/or forceps removal) but is limited to non-
surgical or surgical extractions (pulling teeth) (2 procedure codes per calendar year). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140) Tooth #3 and 14 from August 3, 2023, through November 1, 2023. Therefore, this benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve extraction, erupted tooth 
or exposed root (elevation and/or forceps removal) (D7140) Tooth #20, 21, 22, 23, 26, 27 and 28.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22830, 20930 and 20936 billed for date of 
service February 22, 2023. 
 
You asked the Plan to pay for procedure codes 22830, 20930 and 20936. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says payment for code 22830 is included in 
the payment for code 22612. Codes 20930 and 20936 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, we have confirmed that code 22830 is a column II code to column I code 22612; however, 22830 
was billed with a modifier.  
 
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 procedure code 22830. Our reviewer says that procedure 
code 22830 does not meet criteria for payment. Our reviewer found that the operative report describes 
procedures performed on L2 - L3. Per Medicare guidance, "CPT code 22830 shall not be reported with another 
procedure of the spine in the same anatomic area. However, if the spinal fusion exploration is performed in a 
different anatomic area than another spinal procedure, CPT code 22830 may be reported separately with 
modifier 59 or XS." In this case, this claim denied correctly, as this service was unbundled. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 22830 have not been met. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 22830, 20930 and 20936 billed 
for date of service February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an in-network 
provider on January 10, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you do not agree with the cost 
sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 in-network deductible which applies to the office visit. 
 
 You have been asked to pay a $97.48 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 in-
network deductible which applies to physician/practitioner services, including doctors office visits. This cost 
sharing is a contractual obligation that had not been met at the time the office visit was provided on January 10, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided by 
an in-network provider on January 10, 2023.
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 that you do not meet the criteria for admission to an IRF.

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 you do 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 pay for procedure code 14001 provided on December 6, 2022. 
 
You asked the Plan to pay for procedure code 14001. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 31, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 14001 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 14001 provided on December 6, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP allograft (20930). 
 
You asked the Plan to pre-approve Medtronic Infuse BMP allograft. 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 Medtronic Infuse BMP allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found BMP is not approved for use in the posterior lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic Infuse BMP allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medtronic Infuse BMP allograft (20930).