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

 
We decided that the Plan has to pre-approve the custom fabricated abutments (D6057) for tooth #12 and #14, 
the abutments supported retainer crowns (D6068) for tooth #12 and #14, and a pontic (D6245) for tooth #13. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental work is medically 
necessary, and you cannot chew on your upper left side. The Plan denied your request. The Plan says that  the 
records do not show that the supporting teeth have at least 50% of bone; therefor, the requested dental services 
are not medically necessary. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the requested dental services meet the criteria for coverage. Our physician reviewer found that the 
documentation indicates that dental implant bodies are in place in areas #12 and #14. These implants appear to 
be well integrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve the custom fabricated abutments (D6057) for tooth #12 and #14, the abutments supported retainer 
crowns (D6068) for tooth #12 and #14, and a pontic (D6245) for tooth #13.  
 
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 destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635, 64636). 
   
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan says the 
clinical documentation does not show two medial branch blocks (MBB) provided at least 80% improvement in 
pain for the amount of time the numbing agent was supposed to last. There is no documentation showing other 
conditions contributing to pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary not covered. Medicare rules also say that in order for thermal radiofrequency destruction of lumbar 
paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must have had at 
least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain.  
 
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, 
paravertebral facet joint nerve(s), with imaging guidance. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found there is no documentation submitted that indicates diagnostic blocks 
were performed and that 80% pain relief was achieved on each. 
 
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, paravertebral facet joint nerve(s), with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint 
(64635, 64636).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that you need aide services to help with 
taking your medication and eating. The Plan denied your request. The Plan says you do not qualify for home 
health aide services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health aide services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. You say the enrollee needs physical therapy to gain their strength back to be 
able to use their arms and to walk again. The Plan denied your request. The Plan says the SNF services 
requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The clinical documentation shows that the enrollee requires assessment by skilled 
nursing and therapy but does not show that daily skilled services are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transportation 
was medically necessary, and the enrollee was admitted to the hospital. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each Medicare-covered one-way trip via ground ambulance.  The enrollee has been asked to pay a $225 copayment for the ambulance transportation. This item/service falls 
within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transportation provided on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that these should be considered medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 10, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 12, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 6, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 6, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on 
December 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 30, 2022, billed with 
code G0279. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is an add on code that was billed without an 
appropriate primary procedure.  
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 G0279 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met.  Therefore, we decided that the Plan does not have to 
pay for imaging services provided on August 30, 2022, billed with code G0279.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories (K0108, K0040, K0038, 
K0005, E2617, E2609, E2211, E0973, E0971, E0951). 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that this power wheelchair is 
medically necessary. The Plan denied your request. The Plan says this item is not covered by the Plan when the 
enrollee resides in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories are being requested for use in a SNF or hospital.  Therefore, 
we decided that the Plan does not have to pre-approve a wheelchair and accessories (K0108, K0040, K0038, 
K0005, E2617, E2609, E2211, E0973, E0971, E0951).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a Life2000 home mechanical ventilator. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 Life2000 home mechanical ventilator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided records document that the home ventilator is being requested for use with very low set tidal volumes (150 to 
200 mL) which could be provided by a BiPAP device with average volume assured pressure support (AVAPS) 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 Life2000 home mechanical ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99343 billed for date of service September 
16, 2022.  
 
You asked the Plan to pay for procedure code 99343. You say that you appended a modifier, so this code 
should be paid. The Plan denied your request. The Plan says payment for code 99343 is bundled into payment 
for code 99344. 
 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 99343 
is a column II code to column I code 99344 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99343 billed for date of service September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable cardiac monitor (ICM) (33285). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 the service. Our physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an implantable cardiac monitor (ICM). In summary, there is insufficient 
documentation to support the medical necessity for insertion of an implantable cardiac monitor (ICM) in this 
enrollees clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantable cardiac monitor (ICM) (33285).
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 were admitted to the hospital after a motorcycle accident. You are now medically 
stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says  the enrollee must try and fail Venofer first. 
 
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 Feraheme. Our reviewer says that the 
Plan's step therapy criteria have not been met Our physician reviewer found in this case, the enrollee has not 
tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute 
IRF setting have not been met.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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.