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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you need rehab. The Plan denied your request. 
The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you 
were admitted to the hospital on January 4, 2021 with right hip pain after a fall. You are independent for bed 
mobility and need assistance with walking 60 feet with a walker. You do not have any complex wound care or 
other skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. 
As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that a denial will halt the enrollee's progress. The 
Plan denied your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with aphasia and right hemiparesis secondary to strokes. She was admitted to an inpatient rehabilitation facility 
(IRF) and was dependent for ambulation to 10 feet and needed maximal assist for transfers upon admission. As 
of January 1, 2021 she needs modified assist for walking 68 feet with a hemi cane and for toilet transfers and 
bed mobility. She does not have any skilled nursing needs. She has skilled therapy needs but does not require 
skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the 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 the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller, controller harness and 
electronic connection. 
 
You asked the Plan to pre-approve the expandable controller, controller harness and electronic controller. You 
say that you would like reconsideration because these supplies are medically necessary. The Plan denied your 
request. The Plan says the member's upper limb strength and function are adequate for the member to be able to 
control the power options using their own switches. 
 
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 expandable controller, controller 
harness and electronic controller. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
reveal that the member needs an expandable controller to operate other types of proportional input devices, or 
to operate 3 or more powered seating actuators through the drive control. The documentation does not reveal 
the member needs the expandable controller to operate a separate display,other electronic devices, or for an 
attendant control. The member has functional ability given their ability to feed and groom that would allow 
them to operate any power options through their own individual switches. 
 
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 expandable controller, controller harness and electronic controller have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller, 
controller harness and electronic connection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (CPT 85060) provided to the enrollee on 
August 19, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an inappropriate place of service for physician interpretation. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 85060 
has a PC/TC indicator of 8, which says, "Physician interpretation codes: This indicator identifies the 
professional component of clinical laboratory codes for which separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. This applies to CPT codes 88141 and 85060, and 
HCPCS code P3001-26. No TC billing is recognized because payment for the underlying clinical laboratory 
test is made to the hospital, generally through the PPS rate. No payment is recognized for CPT codes 88141 
and 85060, or HCPCS code P3001-26 furnished to hospital outpatients or nonhospital patients. The physician 
interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test." The 
physician billed 85060 in Place of Service 22, on campus-outpatient hospital, therefore it is not eligible for 
reimbursement. 
 
We looked at this coder's review, the file, and Medicare rules. 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 laboratory services (CPT 85060) provided to the enrollee on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve temporary dentures. 
 
You asked the Plan to pre-approve the dental items. You say that it was recommended that you have your teeth 
extracted and obtain dentures. You say that you would need temporary dentures after this until you receive 
your actual dentures due to health needs. The Plan denied your request. The Plan says temporary dentures are 
not covered services. The Plan also says that you were previously approved for permanent dentures. 
 
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 temporary dentures are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
temporary dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that the 
enrollee tests his blood glucose levels twice per day and uses insulin twice per day at set doses. He does not 
adjust his insulin dose based on the test results. The criteria for coverage are not met; therefore, the CGM 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 a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown (D2750) and core buildup (D2950) for 
tooth #30. 
 
You asked the Plan to pre-approve dental services on tooth #30. You say that you are in severe pain and need 
these services. The Plan denied your request. The Plan says the records show that services were rendered on 
this tooth in 2017. 
 
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. The Plan covers crowns and 
core buildup once per tooth every five plan years. 
 
We looked at the file and Medicare rules. This service exceeds the maximum count allowed per period for 
tooth #30. Based on this information, we decided that the Plan's rules for coverage of dental crown and core 
buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental crown 
(D2750) and core buildup (D2950) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided on 
August 14, 2020. 
 
You asked the Plan to pay for the complete denture - maxillary. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this is not 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 pay for the 
complete denture - maxillary (D5110) provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint block injection. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
fell from a roof and injured your back. You have had physical therapy and chiropractic therapy. The SI joint 
injection is considered experimental/investigational in nature due to the wide variation in effectiveness. The 
services are not 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 a sacroiliac (SI) joint block injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on February 3, 
2020. 
 
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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing is 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 pay for these services. Our physician reviewer found 
the enrollee has a diagnosis of single episode major depressive disorder. It is noted on the GeneSight order that 
the provider is not contemplating an alteration in neuropsychiatric medication for the enrollee. The criteria for 
coverage are not met; therefore, the testing was not 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 pay for the GeneSight Psychotropic Assay rendered on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D 25 hydroxy and glycosylated hemoglobin testing 
provided on May 26, 2020. 
 
You asked the Plan to pay for Vitamin D and glycosylated hemoglobin tests. You say that you are appealing 
with records to show the medical necessity of these tests. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because these tests are not covered for the diagnoses billed and 
were performed for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes G62.9 and R53.83 are not 
among those for which lab tests 82306 or 83036 may be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Vitamin D and glycosylated hemoglobin tests have not been met. Therefore, we decided that the 
Plan does not have to pay for Vitamin D 25 hydroxy and glycosylated hemoglobin testing provided on May 26, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis (0037U) provided on 
July 12, 2020. 
 
You asked the Plan to pay for targeted genomic sequence analysis. You say that this should be covered. The 
Plan denied your request. The Plan says this was 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 pay for targeted genomic sequence analysis. Our 
reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this testing is not medically necessary and is experimental for small cell cancer. 
The enrollee's therapy is and was not dependent on mutational analysis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of targeted genomic sequence analysis have not been met. Therefore, we decided 
that the Plan does not have to pay for targeted genomic sequence analysis (0037U) provided on July 12, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the injections at the L4 level. We decided that the Plan does not 
have to pre-approve the L5 injections.  
 
You asked the Plan to pre-approve the injections. You say that these injections are medically necessary. The 
Plan says that coverage criteria has not been met. 
 
We decided that the Plan has to pre-approve the injections at the L4 level. 
 
The enrollee clearly has a documented disc protrusion impacting the L4 nerve root.  A Transforminal Epidural 
steroid injection at that level is medically reasonable and necessary. 
  
We also decided that the Plan does not have to pre-approve the injections at the L5 level. 
 
The records show there is no stenosis or symptoms that correspond to the L5 level. An injection at that level is 
not medically necessary. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve total electric hospital bed. You say that due to the enrollee's condition, you 
recommend a full electric bed. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because a total electric hospital bed is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered by 
Medicare.  
 
We looked at the file and Medicare rules. The requested total electric hospital bed is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
June 10, 2020. 
 
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 the diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee underwent a PET scan for 
suspicion of cancer. The PET was compared to a computed tomography (CT) scan dated June 5, 2020. The CT 
results were not provided and there is no rationale for the PET scan. The documentation does not support that 
the PET was 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 pay for the positron emission tomography (PET) scan rendered on June 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided from July 1, 2020, to July 
14, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 the outpatient services provided from July 1, 2020, 
to July 14, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy provided.