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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is stable and suitable for admission to an 
IRF. You say that the enrollee requires aggressive therapy and close physician monitoring. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can 
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. 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 a custom fabricated oral appliance used for the 
treatment of obstructive sleep apnea (E0486) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an oral appliance. You say that according to your policy a provider of 
E0486 must be both a dentist and a DME supplier. The providers you have are not a dentist and DME supplier. 
Please approve the GAP coverage. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a custom fabricated oral appliance used for the treatment of obstructive sleep apnea (E0486) to be provided by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology services and injection. You say that you are in need of 
treatment and this eye injection as soon as possible. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network ophthalmologist. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fragile X Mutation testing at the tertiary level for the 
enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available within the network at a non-tertiary level of care. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical group denied the requested referral because the service is available within the network at a 
non-tertiary level of care. Instead, the member was approved to see an in-network non-tertiary provider. The 
review has determined that there is no specific reason why the enrollee would require a tertiary level of care for 
this testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fragile X Mutation testing at the tertiary level for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #11. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
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 the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation provided does not support 
the need for a crown (D2740) for tooth #11. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like dentures but are 
not eligible. The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
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 a 
maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced care planning rendered on October 3, 2019. 
 
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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 advanced care planning rendered on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care, typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit (CPT Code 99223) provided on November 18, 2019. 
 
You asked the Plan to pay for the service. You say that this is the correct place of service for procedure code 
99223. The Plan denied your request. The Plan says the member was outpatient on this date of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The member was outpatient on this date of service billed. The claim shows that the member was not inpatient 
until November 19, 2019 at 1600 hours. The documentation submitted with the dispute states, "admit to 
telemetry unit." A corrected claim is needed for consideration of payment. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for initial hospital care, typically, 70 minutes are spent at the bedside and on the patient's 
hospital floor or unit (CPT Code 99223) provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 20, 2020 by a 
non-network provider. 
 
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 rendered by a non-network provider without 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 referring provider 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 20, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 7, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 7, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve reconstruction of the jaw. 
 
You asked the Plan to pre-approve the reconstruction of the jaw. You say that this service should be covered 
because it is medically necessary. The Plan denied your request. The Plan says that this service is not covered 
under the Plan's medical benefit. 
 
The Plan must follow Medicare rules. Medicare generally does not cover dental services. Medicare rules say 
that if there are no specific coverage rules for an item or service, then that item or service will be covered when 
it is 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 reconstruction of the jaw. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the extent and size of the 
lesion compromises the integrity of the mandible, with a risk of jaw fracture due to the lesion. The differential 
diagnosis of the lesion includes ameloblastoma which is a benign but expanding lesion that can destroy the 
integrity of the jaw. Our reviewer found that final diagnosis would be made upon surgical intervention. This 
type of cyst is not associated with any particular tooth, though it develops from the residual epithelium of a 
tooth germ.  Our physician reviewer also found that, in any case, the extent of the lesion is a medical issue that 
needs to be addressed, and the treatment of the lesion and jaw is a medical concern to preserve the integrity of 
the mandible, and not for implant placement for replacement teeth. 
 
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 reconstruction of the jaw have been met. Therefore, we decided that the Plan 
has to pre-approve reconstruction of the jaw.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the limits set 
in the subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 42 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a collapsible power scooter. 
 
You asked the Plan to pre-approve a collapsible power scooter. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says your current power scooter provides the 
support you need to participate in your daily tasks. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a group 2 power scooter. The group 2 power scooter serves the same purpose as a 
collapsible power scooter. Therefore, we decided that the Plan does not have to pre-approve a collapsible 
power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 22, 2019. 
 
You asked the Plan to pay for the services. You say that the patient presented with Medicare as their primary 
insurance and it was not until April 20, 2020 that the patient gave you the correct insurance information. The 
Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 12 
months or 1 calendar year from the date when the services were rendered. 
 
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 April 21, 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 the services provided on February 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on May 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 should be coded with CPT 81479. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant360 test provided to the enrollee on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is no evidence the member has failed BiPAP 
with backup. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. The enrollee is 
noted to have COPD. There is no evidence that the enrollee has a neuromuscular disease or thoracic restrictive 
disease. The enrollee is noted to use oxygen and several pulmonary medications. There is no evidence that the 
enrollee has ever undergone a sleep study or actually used BiPAP/CPAP, resulting in treatment failure. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal protective equipment (D1999), the extraction 
(D7140) of tooth # 11, and core build up (D2950) for tooth # 15 provided on July 13, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the maximum 
plan benefit of $500 has been exceeded. The Plan also says core build up 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, core build up is not among those 
covered under this benefit. Additionally, the record shows the maximum benefit of $500 has been exceeded 
prior to the date of service. 

Therefore, we decided that the Plan does not have to pay for the personal protective equipment (D1999), the 
extraction (D7140) of tooth # 11, and core build up (D2950) for tooth # 15 provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 6, 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 Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Limb orthosis (L8702). 
 
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says this brace is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. The rules also say that experimental and investigational are not covered. The MyoPro Motion G 
orthosis is considered to be experimental and investigational. Based on this information, we decided that 
Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G Limb orthosis (L8702).