Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
patient is medically stable after an ankle fracture with no evidence of need for supervision by physical 
medicine and rehab physician or need for acute rehab nursing care. Functionally given her current level, though 
she needs physical therapy (PT) and occupational therapy (OT), she does not require IRF level of therapies. 
The patient may benefit from further PT and OT but does not require an intensive therapy program. IRF 
admission is not medically necessary based on the patient?s lack of medical complexity of care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve penile prosthesis (54005). 
 
You asked the Plan to pre-approve the penile prosthesis. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is no documentation showing that 
alternative therapies have been exhausted. 
 
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 penile prosthesis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that you have had a trial of either vacuum 
erection devices or an intra-urethral medication. 
 
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 penile prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve penile prosthesis (54005).
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. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF.
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 based on review of extensive available records, the enrollee does not meet Medicare criteria for coverage for an IRF admission. The enrollee is generally medically stable with debility and prolonged hospital/LTACH stay with no recent neurological or orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. Currently the enrollee still requires physical therapy (PT) and occupational therapy (OT). While the enrollee may benefit from continuing PT and OT, there is no evidence of need for skilled and intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee has been receiving PT and OT all along and has a chronic decubitus ulcer that will not heal during the IRF stay. Admission to an IRF is not medically necessary based on lack of medical complexity. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213). 
 
You asked the Plan to pre-approve the upper partial denture (D5213). The Plan denied your request. The Plan 
says the service 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 the 
upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #20.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that the enrollee received this service less than 60 months ago.
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, crowns are limited to once per tooth per 60 months. The record shows that the enrollee received a crown (D2750) on tooth #20 on June 13, 2019 and the enrollee's crowns benefit for tooth #20 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265), a surgical placement of an implant body: endosteal implant (D6010), an interim abutment (D6051), an abutment supported porcelain/ceramic crown (D6058), a custom fabricated abutment (D6057), and a bone graft at time of implant placement (D6104).
You asked the Plan to pre-approve the biologic materials, endosteal implant, interim abutment, abutment supported porcelain/ceramic crown, custom fabricated abutment, and bone graft. You say that a partial denture is needed due to missing teeth. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 biologic materials to aid in soft and osseous tissue regeneration (D4265), a surgical placement of an implant body: endosteal implant (D6010), an interim abutment (D6051), an abutment supported porcelain/ceramic crown (D6058), a custom fabricated abutment (D6057), and a bone graft at time of implant placement (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on March 31, 
2020. 
 
You asked the Plan to waive the copayment for spinal injection. You say that you have had this service in the 
past and have never had to pay more than the physician fee. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $250 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay a $250 copayment for spinal injection. The spinal injection falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 spinal injection 
provided on March 31, 2020. 
  
Our decision is only about the March 31, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty in conjunction with extractions, therapeutic parenteral drugs, first 15 minutes of deep sedation/general anesthesia, and two subsequent 15 minute increments of deep sedation/general anesthesia.
You asked the Plan to pre-approve the alveoloplasty, therapeutic parenteral drugs, and deep sedation/general anesthesia services. You say that these services are necessary because you need dentures. The Plan denied your request. The Plan says these services are not covered 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 the alveoloplasty in conjunction with extractions, therapeutic parenteral drugs, first 15 minutes of deep sedation/general anesthesia, and two subsequent 15 minute increments of deep sedation/general anesthesia.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you went to urgent care 
first. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $265 for this 
service. 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 ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 to 
March 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you do not see the enrollee and depend on the 
ordering provider to verify network status. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is 
also out-of-network with the Plan. 
 
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 medical services provided on February 19, 
2020 to March 4, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture. The Plan 
denied your request. The Plan says this service exceeds the benefit allowance. The Plan also says this service is 
limited to one per every 60 months. 
 
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, maxillary dentures are limited to once 
per 60 months. The record shows that you received a maxillary partial denture (D5213) on December 17, 2018, 
and your maxillary dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve a maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 We decided that the Plan does not have to waive the deductible for the cataract surgery provided on March 12, 
2020. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that you had already paid your 
$1,000 deductible at the time of surgery. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible that applies towards the cataract surgery.  
 
The cataract surgery you asked the Plan to waive the deductible for falls within the ?Physician/Practitioner 
services, including doctor?s office visits? benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible that applies towards outpatient physician surgical 
services. This cost sharing is a contractual obligation that had not been met at the time the cataract surgery was 
received on March 12, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the 
cataract surgery provided by on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on
February 25, 2020.
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to
determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate
coding.
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479
for date of service February 25, 2020.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
comprehensive genomic profile (CGP) testing provided on February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (49657) provided on December 31, 2019.
You asked the Plan to pay for surgical assistant services. You say that these services were requested by the in-network physician. The Plan denied your request. The Plan says these services are not covered for this provider.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (49657) provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you were running low on medicine and you 
panicked. The Plan denied your request. The Plan says these services could have been provided in-network. 
 
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. 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 physician 
services provided on March 16, 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 services provided to the enrollee by an out-of-network provider on February 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on February 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to you by an out-of-network provider on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 22, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on January 31, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be placed adjacent to the 
CPT code in the comment/narrative field. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant360 testing provided on January 31, 2020.