Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology services (81120, 81121, 81173, 81201, 
81235, 81272, 81275, 81310, 81311, 81314, 81321, 81404, 81405, & 81406) provided June 10, 2020. 
 
You asked the Plan to pay for the molecular pathology services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the correct CPT code was not used to describe the 
service at issue. 
 
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 CPT codes 81120, 81121, 81173, 81201, 81235, 81272, 81275, 81310, 81311, 81314, 81321, 
81404, 81405, & 81406 are not supported in the medical record. Specifically, per Medicare Local Coverage 
Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in 
[Solid Tumor] Cancers (A55624), this pathology service must be billed using CPT code 81479. Based on this 
information, we decided that Medicare rules for coverage of the molecular pathology services have not been 
met. Therefore, we decided that the Plan does not have to pay for molecular pathology services (81120, 81121, 
81173, 81201, 81235, 81272, 81275, 81310, 81311, 81314, 81321, 81404, 81405, & 81406) provided June 10, 
2020.
Appeal type: Practitioner Services
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 you would like reconsideration 
because this procedure is medically necessary. The Plan denied your request. The Plan says this service is 
experimental. 
 
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 requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature of  long-term outcomes of this 
procedure. The  evidence in the peer reviewed scientific literature remains insufficient to support long term 
safety and efficacy of this procedure as a treatment for chronic 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 the Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the therapy needs are not inherently complex and do not require an interdisciplinary 
approach. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. 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 inpatient 
rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you lost your dentures while you were out of 
town. You say that you cannot eat or talk well because you have no teeth. You also say that because of the 
shape of your lower jaw you are only requesting an upper denture. The Plan denied your request. The Plan says 
dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 denture every 
5 plan years has been exceeded. The record shows that you received dentures. Therefore, we 
decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (99601) provided on June 8, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that this code is supported by the records. The 
Plan denied your request. The Plan says this code is not valid for Medicare. 
 
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 CPT code 99601 is not supported in the medical record. Specifically, this code has a status 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.  
Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on June 
8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 3) and the other preventive 
dental service (D1999). 
 
You asked the Plan to pre-approve the dental services. You say that you were advised by the office that your 
crowns were denied. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered 
service. The Plan also says other preventive dental service is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921 x 3) and the other preventive dental service (D1999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute IRF admission is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an 
IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a hip fracture after a fall. Her medical problems are stable. There are no identified problems that 
need inpatient medical management. Additionally, there are no complex nursing or rehabilitation needs. 
  
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 
There is not a reasonable expectation that this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 70553) you received on March 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that that claims or claim lines that have been 
determined to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (CPT 70553) you received on March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you have dialysis three times a week. The 
Plan denied your request. The Plan says the benefit can be exceeded. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that with this request, you will have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you would like plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has extensive stage high grade neuroendocrine cancer that is consistent with small 
cell cancer. The enrollee is being treated already with Carboplatin/Etoposide. The use of Tecentriq in this 
setting is not FDA approved nor is it supported in any of the CMS approved compendia. Therefore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 3, 2020. 
 
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says two or more diagnosis codes are mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10 code. 
 
It is not appropriate to report left and right diagnosis codes when a bilateral code is available. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for the medical services provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk, and have not fully regained 
your strength. The Plan denied your request. The Plan says your care is not complex, and you do not need a 
team of providers. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for lactic acidosis and systemic inflammatory response 
syndrome. You were discharged home and are receiving home health care. Your medical problems are stable. 
The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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. The medical record supports a need for physical 
and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is 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 above. 
 
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 required minimal assistance for grooming, lower body dressing, and toileting. 
You required minimal assistance to stand up. You required contact guard assistance to sit down. You required 
minimal assistance to walk 40 feet times three using a rolling walker. The documentation does not support that 
you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your care 
needs can be met at a lower 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that your financial institution will not allow you to 
pay $470 for the extraction. You say that you live off social security and are trying to save every penny. The 
Plan denied your request. The Plan says services are only covered when performed by a participating general 
dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when received from an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve the extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), and 
the cone beam CT capture (D0364) provided on June 18, 2020. 
 
You asked the Plan to pay the in network rate for the oral exam and CT capture. You say that you could not 
find an in network dentist that would help you right away. You say that you needed these services so you had 
to go to an out of network dentist. You also say that these bills have caused hardship for you. The Plan denied 
your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the 
frequency limit has been exceeded. The Plan also says that the cone beam CT capture is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that the plan paid for this service that you 
previously received on March 4, 2020. Additionally, the cone beam CT capture is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited 
oral evaluation (D0140), and the cone beam CT capture (D0364) provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient hospital care provided
 was medically necessary as the enrollee was stable for transfer to a contracted 
 
 
facility. The Plan denied your request. The Plan says the inpatient hospital care provided from was not 
medically necessary as the enrollee was stable for transfer to a contracted facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided was not medically 
necessary as the enrollee was stable for transfer to a contracted facility. Our physician reviewer found the 
review indicates that all inpatient care provided was not 
needed on an emergent basis and could have been performed in Plan. The documentation indicates that after 
2:27 pm the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to 
a Plan facility for continued hospital care. The review has indicated that the treating physician did not 
document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any 
dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided.