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

 
We decided that the Plan does not have to pre-approve OneTouch Verio diabetic test strips (A4253) at a 
quantity of 300 strips per 100 days. 
 
You asked the Plan to pre-approve 300 OneTouch Verio diabetic test strips per 100 days. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for the requested quantity of diabetic test strips have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of OneTouch Verio diabetic test strips 
(A4253) at a quantity of 300 strips per 100 days. have been met. Specifically, medical records to support the 
medical necessity of the requested quantity of diabetic test strips have not been provided for review. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio diabetic test strips (A4253) 
at a quantity of 300 strips per 100 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) 
and the resin-based composite - one surface, anterior (D2330) provided on March 1, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that due to the pandemic you were unable to 
get dental care from 2020-2021, so now you need four teeth repaired. You are asking for the limitation 
frequency to be extended to cover these services. The Plan denied your request. The Plan says you received 
two procedure codes of resin-based composite on February 10, 2022, and therefore have exhausted your yearly 
limit for resin-based composites. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers two 
procedure codes of resin-based composites per year when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we found that your annual benefit for 
these services has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite - two surfaces, anterior (D2331) and the resin-based composite - one surface, anterior (D2330) 
provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for composite dressing (A6204) provided on February 21, 2022. 
 
You asked the Plan to pay for composite dressing. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was billed with an incorrect 
place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the billed place of service should indicate the 
place in which the item is being used. Medicare rules say that if a treating practitioner applies surgical 
dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered 
incident to the professional services of the health care practitioner and are not separately payable. 
 We looked at the file and Medicare rules. In this case, the enrollee appears to have received these bandages as 
incidents to the professional services of the health care practitioner. These bandages as billed are not separately 
payable. Based on this information, we decided that Medicare rules for coverage of composite dressing have 
not been met. Therefore, we decided that the Plan does not have to pay for composite dressing (A6204) 
provided on February 21, 2022.
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 are appealing the denial of IRF. The Plan denied 
your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's 
condition they don't meet the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 was admitted for COVID-19 infection. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 the enrollee is not able to safely 
transition to a lower level of care due to the severity of her wounds. The Plan denied your request. The Plan 
says the enrollee's medical record shows that they do not meet Medicare guidelines. 
 
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 enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on 
January 15, 2022.

You asked the Plan to reimburse you for the COVID-19 at-home test kit. The Plan denied your request. The Plan says the COVID-19 at-home test kit is a non-covered benefit.

The Plan must follow Medicare rules. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on January 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monitoring device (A9279) provided on December 1, 2021. 
 
You asked the Plan to pay for a monitoring device. You say that the item at issue is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 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 code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of a monitoring device have not been met. Therefore, we decided that the Plan does not have to pay 
for a monitoring device (A9279) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and topical application of fluoride varnish (D1206) provided on February 1, 2022, and the intraoral - periapical 
first radiographic image (D0220) provided on February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oral evaluation, prophylaxis, topical fluoride, and intraoral image. You say 
that you were told this provider was in-network. The Plan denied your request. The Plan says the services have 
been provided out-of-network and were not approved in advance. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan only covers in-
network services that are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the oral evaluation, 
prophylaxis, topical fluoride, and intraoral image are not covered because they were provided out-of-network. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis 
(D1110), and topical application of fluoride varnish (D1206) provided on February 1, 2022, and the intraoral - 
periapical first radiographic image (D0220) provided on February 14, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 24, 2022, billed with 
codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this must be billed as a single code. Therefore, 7 of the codes will be paid, 
and the rest are denied. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. This testing is an NGS panel that was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on January 
24, 2022, billed with codes 81206, 81235, 81292, 81301, and 81321.
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 currently meets LTAC 
admission criteria. The Plan denied your request. The Plan says the enrollee's medical record shows that they 
do not meet the Medicare guidelines. 
 
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 enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift (E0635) provided on February 9, 2022. 
 
You asked the Plan to pay for the patient lift. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says payment cannot be made to a supplier not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the patient lift (E0635) provided on 
February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services (S2900, 82948-QW, 97535-
GP, 97530-GP) provided from February 16, 2022, through February 18, 2022. 
 
You asked the Plan to pay for the services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the claim has not been billed as required for 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient hospital services (S2900, 82948-QW, 97535-GP, 97530-GP) provided on November 9, 2020, have been met. In this case, no medical 
documentation has been provided to corroborate the services as billed. Therefore, we decided that the Plan does 
not have to pay for the outpatient hospital services (S2900, 82948-QW, 97535-GP, 97530-GP) provided from 
February 16, 2022, through February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. A 
similar study was approved, and the Plan needs results of the prior approved study that show the need for 
repeat imaging, or confirmation from the physician that the prior approved study was not performed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a computed tomography (CT) scan of 
the chest (71260) have been met. The Plan sent several requests for missing medical information that were not 
all returned. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) 
scan of the chest (71260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed an emergency root canal. You say 
that you have seen this dentist in the past and it was covered. You also say that you did not know that you had 
been assigned a different dentist. The Plan denied your request. The Plan says dental services performed by an 
out of network dentist are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit when received out of network. Therefore, we decided that the Plan does not have to 
pay for the consultation (D9310) provided on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on November 17, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have never had to pay out-of-
pocket for this test before. The Plan denied your request. The Plan says you were charged this cost sharing 
correctly.  The Plan says that because the allowed amount for this service ($110.04) is less than your 
copayment obligation, you are responsible for the full allowed 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 $135 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $135 copayment for the CT scan. The CT scan falls within the radiological 
diagnostic 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 the computed 
tomography (CT) scan of the chest you had on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there is no documentation of an order for 
the testing which was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
January 27, 2022, have been met.  In this case, no medical records have been provided from the ordering provider. In addition, there is no test 
requisition form indicating these tests were ordered by the enrollees treating provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #19 (D2750) provided on December 30, 2021. 
 
You asked the Plan to pay for a crown. You say that a crown is a covered service. The Plan denied your 
request. The Plan says a crown (D2750) is not covered by your dental 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 pay for a crown 
on tooth #19 (D2750) provided on December 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) home health physical therapy visits (CPT 
code G0151 x12). 
 
You asked the Plan to pre-approve home health physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says the enrollee requires little to no help withstanding up, getting to the toilet, and transferring to the shower or tub. The Plan states the approved visit(s) should be enough to 
complete the enrollee's goals, teach them a home exercise program, and establish a safe discharge plan. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for the enrollees condition beyond what was approved by the health plan. The enrollee has 
had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. The enrollee has been given education on home exercises, home safety and hip 
precautions. The enrollee has been instructed on safety measures, an emergency plan, and fall precautions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve twelve (12) home health physical therapy visits (CPT code G0151 
x12).