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

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth  
number 18. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan?s 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of a crown for tooth 
number 18 as it does not have significant break down.  
 
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 this item 
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 this item. Our reviewer says that a 
crown for tooth number 18 is not medically necessary. Our physician reviewer found that tooth# 18 appears to 
have breakdown of the mesial aspect and has an existing restoration that involves the Meso-occlusal surfaces.  
The Plan states "In general, criteria for crowns will be met only for permanent teeth needing multi-surface 
restorations where other restorative materials have a poor prognosis. Permanent molar teeth must have 
pathologic destruction to the tooth by caries or trauma, and should involve four or more surfaces and two or 
more cusps."  In this instance, tooth# 18 does not have four or more involved surfaces, and can be restored with 
conventional restorative materials.  There is insufficient damaged structure to support the need for a full 
coverage restoration. 
  
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 this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown (D2740) for tooth number 18.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not FDA-approved for treatment of GE junction carcinoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the prescriber submitted 
2 journal articles that do not reflect the enrollee's clinical situation. The drug is not FDA approved, or 
compendium supported for the requested use. There are no supporting citations in PubMed. The documentation 
does not support that the requested use is reasonable and necessary for the enrollee. The documentation does 
not support that the requested use is safe and effective for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Mvasi for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PET scan with concurrently acquired CT for 
attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of an Axumin PET scan in the setting of newly 
diagnosed prostate cancer have not been demonstrated in the peer-reviewed literature. 
 
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 PET scan. Our physician reviewer 
found per package insert Axumin, it is indicated for patient with rising PSA after previous treatment to identify 
recurrent disease, it is not approved for initial staging. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PET scan with concurrently acquired CT for attenuation correction and anatomical 
localization imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the administration of a drug provided on 
March 18, 2020. 
 
You asked the Plan to waive the copayment for the administration of a drug. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $325 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay the allowed amount of $50, which is less than the $325 copayment for the 
administration of a drug. The administration of a drug falls within the outpatient surgery and other medical 
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 administration of a drug provided on March 18, 2020.
Appeal type: Surgery
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. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for practitioner visits during a nursing facility 
stay (99309, 99316) on July 6 and July 24, 2020. 
 
You asked the Plan to waive the copayments for practitioner visits. You say that no one came to see you while 
you were at the skilled nursing facility. The Plan denied your request. The Plan says the correct copayments 
were 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 $50 
copayment for each specialist or any other physician or other health care professional visit for Medicare-
covered benefits in a specialist setting.  
 
The case record shows you had practitioner visits on July 6 and July 24, 2020. You have been asked to pay a 
$50 copayment for each one of two practitioner visits. Practitioner visits 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 copayments 
for practitioner visits during a nursing facility stay (99309, 99316) on July 6 and July 24, 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 an LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of an LTACH admission. 
 
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) 
for COVID-19. The enrollee is not intubated/ventilated, but she is requiring the use of a bilevel airway pressure 
device (BiPAP). There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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 pay for physician's services provided on July 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 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 July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on June 16, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the rendering provider is out-of-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. 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 lab tests provided on June 16, 2020 by an out of 
network (OON) provider.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on November 22, 2020 after a fall and underwent surgical repair of tibia and fibula fractures on 
December 2, 2020. He is unable to tolerate ambulation secondary to balance and non-weight-bearing 
precautions. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but 
does not require an intensive therapy program 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT Home Care Services provided from November 27, 
2020, forward. 
 
You asked the Plan to pre-approve the services. You say that you have been in physical therapy for over a 
month now and it is just now starting to work. You state you believe if you can get this extended then you can 
get closer to normal function. The Plan denied your request. The Plan says the documentation has outlined your 
ability as improved function. The Plan states the improved functionality is evidenced by your ability to 
ambulate 100 feet three times while your physical therapist is there with a four wheeled walker and transfer 
from sitting to standing at supervisory level. The Plan states you no longer require the skilled needs of a 
physical therapist based on your level of mobility progress and ability to perform a home exercise program. 
The Plan states it is no longer a taxing effort for you to leave the home, so you are no longer considered home 
bound. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found the records do not show a decline in functional or medical status or care plan to warrant further skilled 
PT visits. Skilled PT visits are not required to effectively provide treatment, care, and/or services which are 
medically necessary for the patient.  
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve PT Home Care Services provided from November 27, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on 
February 3, 2020. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable as 
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. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, this code was billed with 
diagnosis code G92 (toxic encephalopathy) as the first listed/primary diagnosis code. This diagnosis code is a 
secondary only diagnosis and cannot be used for the primary, first-listed or principal diagnosis for any 
procedure or service. Based on this information, we decided that Medicare rules for coverage of the initial 
hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial hospital care services coded 99222 provided on February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an upper endoscopy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have complaints of nausea abdominal pain, and gastroesophageal reflux (GERD). An exam showed mild pain 
and tenderness in the right upper quadrant of your abdomen. You were prescribed pantoprazole but did not fill 
the prescription. The records do not show you have a condition for which an upper endoscopy is covered. The 
services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upper endoscopy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic management and training provided on June 23, 
2017. 
 
You asked the Plan to pay for orthotic management and training (97760). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the modifier GP is missing from the claim. 
 
The Plan must follow Medicare rules. The rules state that providers must bill services with a GP modifier for 
therapy services. 
 
The claim is missing the required modifier GP. Based on this information, we decided that Medicare rules for 
coverage of services billed without a modifier have not been met. Therefore, we decided that the Plan does not 
have to pay for orthotic management and training provided on June 23, 2017.
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 the enrollee would have his needs best 
met at the LTACH level of care. The Plan denied your request. The Plan says the enrollee will receive adequate 
care at the current facility. 
 
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 patient is a 48-year-old male who was admitted to the current acute care hospital 
with hypotension, COVID-19, acute kidney injury, cellulitis, diarrhea, and sacral/lower extremity ulcers. He 
was treated with IV fluids, antibiotics, rectal tube, and dialysis. The course was complicated by hematemesis, 
anemia, and bacteremia which were treated. He underwent diverting colostomy and wound debridement. 
Recent notes state that he is requiring Levophed for hypotension, however, leukocytosis and diarrhea are 
resolving and he is on oral antibiotics. He requires PT for weakness and chronic dialysis. 
 
The patient appears to be stable and improving at this time, requiring additional short-term acute care services 
which can be received in the current setting. The patient does not require services at the LTACH that are not 
already available at the current hospital. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered when the patient's treatment has 
completed and it is clinically 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 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.