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

We decided that the Plan does not have to pre-approve MTHFR testing. 
 
You asked the Plan to pre-approve MTHFR testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the MTHFR gene for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant. 
Based on this information, we decided that Medicare rules for coverage of MTHFR testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve MTHFR testing.
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 enrollee would benefit from intensive therapy in 
the IRF setting. The Plan denied your request. The Plan says the enrollee's condition is stable, and therapy can 
be provided at lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 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 cervical spinal surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical record does document a need for physical and occupational therapy, it 
does not document a need for an intensive rehabilitation 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 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 admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the time in the hospital has not been completed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include oxygen supplementation, BIPAP support, intravenous 
antibiotics, surveillance laboratory studies, wound care, and therapy services. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve Xifaxan. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan.  
 
Benefits for Xifaxan may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation (D9310) and surgical extractions (D7210) 
to be performed by a Periodontist. 
 
You asked the Plan to pre-approve the dental services. You say that your teeth are falling apart and you are 
having difficulty heating. You do not have the funds to cover the cost. The Plan denied your request. The Plan 
says dental services rendered by a Periodontist are not covered. 
 
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.  The health plan contract specifically says that services must be 
performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 
consultation (D9310) and surgical extractions (D7210) to be performed by a Periodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cystouroscopy and biopsy to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the cystouroscopy and biopsy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the services are not emergent. These services are 
available from in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
cystouroscopy and biopsy to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-fabricated post/core and crown for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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 pre-
fabricated post/core and crown for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a nuclear bone scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that in this clinical situation, alternate imaging would be more appropriate in assessing 
the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable or necessary. Our physician reviewer found a review of the records 
shows a request for a 3 phase bone scan of the feet (CPT 78315) which is a very reasonable request when there 
is clinical suspicion of osteomyelitis. The 3 phases include blood flow, blood pool and delayed imaging. This 
sequence is very sensitive for osteomyelitis. The denial is for a SPECT bone scan (CPT 78320) which is not the 
same scan. In summary the enrollee fulfills necessary criteria for medical necessity for the requested 
radionuclide 3 phase bone scan (CPT 78315). 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a nuclear bone scan for the enrollee.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE).
You asked the Plan to pre-approve transthoracic echocardiography. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that routine (yearly) re-evaluation of patients with heart
failure (systolic or diastolic) in whom there is no change in clinical status is deemed 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 transthoracic echocardiography. Our
reviewer says that the documentation does not support that the requested services are medically reasonable or
necessary. Our physician reviewer found the enrollee has a stable mild-moderate non-ischemic cardiomyopathy
and is maintained on guideline directed medical therapy. The enrollee has no symptoms and signs of congestive
heart failure on the enrollee's prior visit in June 2020 and no report of any changes in symptoms since that time.
The enrollee has had 2 transthoracic echocardiograms in the past year (December 2019 and May 2020) which
showed no significant valvular heart disease and an EF of 41% on the May study which showed no significant
change from December 2019. In the absence of any change in clinical status or symptoms, the enrollee does not
currently meet the Medicare LCD criteria for repeat echocardiogaphy (see below) nor is repeat
echocardiography recommended this frequently by published guidelines in the absence of a change in clinical
condition, new symptoms and signs, intercurrent decompensated CHF, MI or arrhythmia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transthoracic echocardiography have not been met. Therefore, we decided that
the Plan does not have to pre-approve transthoracic echocardiography (TTE).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for needle electromyography; cranial nerve supplied muscle(s), unilateral 
(CPT Code 95867) and neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 
1 method (CPT Code 95937) provided on February 19, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 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 services. Our physician reviewer found the review indicates that the medical records 
support that the needle electromyography; cranial nerve supplied muscle(s), unilateral (CPT Code 95867) and 
neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT Code 
95937) was provided on February 19, 2020. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
needle electromyography; cranial nerve supplied muscle(s), unilateral (CPT Code 95867) and neuromuscular 
junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT Code 95937) provided 
on February 19, 2020.  
 
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 transport accessory for a wheelchair (K0108). 
 
You asked the Plan to pre-approve the transport accessory. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transport accessory for a wheelchair (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures (D5213, D5214), interim partial 
dentures (D5820, D5821), crown lengthening (D4249), post and core additions (D2954), retainer crowns 
(D6740, D6793), precision attachments (D5862), and pontics (D6245, D6253). 
 
You asked the Plan to pre-approve partial dentures, interim partial dentures, crown lengthening, post and core 
additions, retainer crowns, precision attachments, and pontics. You say that these services should be covered. 
The Plan denied your request. The Plan says these services are not covered. 
 
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, it covers partial dentures only once 
every five years. The record shows that you received upper and lower partial dentures in 2019. The other 
requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve partial dentures (D5213, D5214), interim partial dentures (D5820, D5821), crown 
lengthening (D4249), post and core additions (D2954), retainer crowns (D6740, D6793), precision attachments 
(D5862), and pontics (D6245, D6253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crown, teeth 12, 29 (D2740) core buildup 
including pins, tooth 29 (D2950) prefabricated post and core in addition to crown, tooth 12 (D2954) 
periodontal scaling and root planning (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the records provided should support the 
necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered 
under the plan benefits. 
 
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 
porcelain crown, teeth 12, 29 (D2740) core buildup including pins, tooth 29 (D2950) prefabricated post and 
core in addition to crown, tooth 12 (D2954) periodontal scaling and root planning (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (dental code 
D4341). 
 
You asked the Plan to pre-approve dental service. You say that the periodontal scaling needs to be redone. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
exceeds the frequency limit for coverage of this procedure. 
 
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 periodontal 
scaling and root planing for one procedure per quadrant every two plan years, not to exceed four unique 
quadrants every two plan years. 
 
We looked at the file, the Plan?s rules, and Medicare rules. The enrollee received this service previously on 
June 12, 2019 and June 19, 2019, therefore the benefit for this service is exhausted at this time. Based on this 
information, we decided that the Plan's rules for coverage of dental service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve periodontal scaling and root planing (dental code D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ForeSeeHome system. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that precautionary devices are considered non-medical in 
nature and are not covered. 
 
The item at issue is a ForeSeeHome system. This item is a precautionary device that does not contribute to the 
treatment of an illness or injury and is not covered by Medicare. Therefore, we decided that the Plan does not 
have to pre-approve a ForeSeeHome system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast prosthetics (L8033, L8035). 
 
You asked the Plan to pre-approve the breast prosthetics. You say that the custom breast prosthesis is medically 
necessary. The Plan denied your request. The Plan says the records provided do not support the items 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. No medical records pertaining to the requested items have been 
submitted. The records provided have insufficient clinical information to determine if coverage criteria have 
been met. The plan made multiple requests for additional records. Based on this information, we decided that 
Medicare rules for coverage of the breast prosthetics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve breast prosthetics (L8033, L8035).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 93297) provided on April 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a column II 
code and cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the CPT code 93297 is a column II code to column I code 
93296, which was paid for this date of service. However, a NCCI code pair search for these two codes shows 
that there is no column I/column II relationship between these codes. The Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services (CPT 93297) provided on April 1, 2020.  
 
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 the power seat elevation system (E2300) power standing 
system (E2301 and stand and drive package (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that this is a replacement of the exact 
power wheelchair the plan had approved. There were some accessories that were not covered under Medicare, 
therefore the entire wheelchair should not be denied. The Plan denied your request. The Plan says these items 
are not primarily used to serve a medical purpose and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the power seat elevation system (E2300) power standing system (E2301 and stand and drive 
package (K0108).