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

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on 
September 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like to know what the surgery was 
for. You also say that you had a tooth removed. The Plan denied your request. The Plan says tooth #31 was 
extracted and billed as D7210. The Plan says that you do not have any responsibility for the extraction. The 
Plan also says the unspecified preventive 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 pay for the 
unspecified preventive service (D1999) provided on September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion. 
 
You asked the Plan to pre-approve the transforaminal lumbar interbody fusion. You say that you have not been 
able to cook, clean, or stand to support your everyday life. You say that you are experiencing pain and cannot 
control your bodily functions. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
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 transforaminal lumbar interbody 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a half pack per day smoking history since 
she was fourteen years old. Medical necessity is not supported for the requested procedure when the enrollee is 
a smoker. There is no discussion that the enrollee would participate in smoking cessation for six weeks prior to 
surgery. The September 21, 2020, neurosurgical consultation notes that she has not undergone any 
conservative management." The enrollee has a history of chronic intermittent low back pain and has undergone 
physical therapy and lumbar epidural injections in the past. There is no indication that the enrollee has failed 
at least three consecutive months of physician-supervised/recent conservative medical management including 
exercise, nonsteroidal and/or steroidal medication, physical therapy and lifestyle modification. Therefore, the 
requested L5/S1 right TLI of decompression, posterior arthrodesis, and laminectomies is not medically 
reasonable or 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 the transforaminal lumbar interbody fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the MRI, spinal canal and contents, lumbar; without contrast 
material (CPT Code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says that there is insufficient documentation to verify if the service is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
radicular pain (pain with radiation) is indication for study. This was a telehealth visit and therefore the lack of 
physical exam findings of weakness, especially in the presence of radicular pain, should not be used to argue 
against the study. 
 
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 MRI have not been met. Therefore, we decided that the Plan has to pre-
approve the MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI, brain (including brain stem); without contrast material, 
followed by contrast material(s) and further sequences (CPT Code 70553). 
 
You asked the Plan to pre-approve the MRI. You say that they voided the original authorization for CPT code 
70552, per radiologist request; ordered CPT code 70553 because the code that was approved is no longer a 
valid code. The Plan denied your request. The Plan says that the same test or one like it is on file for the 
enrollee and is still in effect. The Plan states they do not show the results of this study, or if there are plans for 
the study. The Plan states the approved study may show the enrollee's doctor what they needed to see in order 
to treat the enrollee's problem (condition). The Plan states further imaging cannot be approved without 
knowing the outcome of the prior approved study and there is an approval for an MRI of the brain with contrast 
(70552). 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
the prior MRI was cancelled because it did not have request for contrast. The original MRI is voided as the 
second MRI is medically necessary and appropriate. The original MRI without contrast was not performed and 
was not desired to be performed. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further 
sequences (CPT Code 70553).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (99213, 81003) provided on June 30, 2020. 
 
You asked the Plan to pay for an office visit. You say that these services were provided by an eligible provider. 
The Plan denied your request. The Plan says that these services were billed with an ineligible provider 
taxonomy. 
 
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 reported NPI shows that the billing provider is eligible to bill for their 
services. Though the Plan states that the provider billed with an incorrect taxonomy, the Plan has not provided 
a rule that would indicate that this is not payable. Therefore, we decided that the Plan has to pay for an office 
visit (99213, 81003) provided on June 30, 2020.
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 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 be able to perform fifteen hours per week of rehabilitative services 
with 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81121, 81173, 81120, and 81201) 
provided on August 27, 2020. 
 
You asked the Plan to pay for Guardant360 testing. You say that this should be covered because it is not 
available in-network. The Plan denied your request. The Plan says this was not billed with sufficient provider 
information. 
 
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 81121, 81173, 81120, and 81201 are not supported in the medical record. Guardant360 
testing should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 testing (81121, 81173, 81120, and 81201) provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The 
Plan says that the enrollee can stay in the hospital to finish treatments. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on April 
24, 2019. 
 
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 the claim was filed past the allowed twelve-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 17, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for outpatient hospital services provided to the enrollee on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) 
debridement of nail(s) by any method (11721) paring or cutting of benign hyperkeratotic lesion (11056) 
provided August 20, 2020. 
 
You asked the Plan to waive the copayment for the outpatient podiatry services. You say that you are on 
financial aid with them, but they do have two partners for dental and podiatry, so you have never been billed 
for these. You do not feel you should have to pay this now. The Plan denied your request. The Plan says this 
claim was processed and the correct copayment was applied per the Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for specialty physicians.  
 
You have been asked to pay $50 copayment for the outpatient podiatry services. The outpatient podiatry 
services fall within the Physician/Practitioner services, including doctor's office visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the outpatient office visit (99213) debridement of nail(s) by 
any method (11721) paring or cutting of benign hyperkeratotic lesion (11056) provided August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeve 
(E0673) provided to the enrollee on September 11, 2020. 
 
You asked the Plan to pay for these services. You say that the patient's physician ordered the DME item used 
to prevent the patient from developing deep vein thrombosis. The Plan denied your request. The Plan says that 
the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that claims for E0675 will be denied as not reasonable and 
necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and 
sleeve (E0673) provided to the enrollee on September 11, 2020.
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 is very motivated and willing to 
participate in her therapy. You say that all of the enrollee's doctors say that she is a great candidate to complete 
medical rehabilitation. You say that the enrollee had a kidney stone which caused an infection and caused her 
body to start shutting down. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. The Plan says that the enrollee can safely receive the services needed in another 
setting. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 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. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care (G0378) provided October 
12, 2020. 
 
You asked the Plan to waive the copayment for the observation care. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient hospital services.  
 
You have been asked to pay a $225 copayment for the observation care. The observation care falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for observation 
care (G0378) provided October 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired 
computed tomography (CT). 
 
You asked the Plan to pre-approve the requested PET/CT scan. You say that the records provided support the 
need for the requested imaging. The Plan denied your request. The Plan says that the enrollee's level of proteins 
made by the prostate is too low for the requested imaging study to be helpful in treatment. The Plan says that 
the requested imaging is not medically necessary. 
 
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 pre-approve the requested PET/CT scan. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found, per the package 
insert, Axumin is indicated for suspected prostate cancer recurrence, based on elevated PSA levels. Our 
physician reviewer found that the enrollee has a history of prostate cancer and a rising PSA. The requested 
treatment is medically reasonable and appropriate. 
 
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 requested PET/CT scan have been met. Therefore, we decided that the Plan 
has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the out of 
network provider would be responsible for securing a prior authorization. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 31, 2020.