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 you need IRF care to regain your maximum function. 
The Plan denied your request. The Plan says an intensive rehabilitation program is 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 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic assay provided on March 30, 
2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic assay. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not supported by 
the documentation.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that no medical records were provided from the prescribing physician. This means the 
GeneSight Psychotropic assay at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the GeneSight Psychotropic assay provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging (capsule endoscopy) for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that endoscopic studies are negative for a source of bleeding 
and there are clinical symptoms which raise for concern of gastrointestinal obstruction or Zenker's 
diverticulum. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has iron deficiency anemia. The record indicates that the 
enrollee underwent upper endoscopy in 2019 that demonstrated a bleeding source in the stomach and had an 
incomplete colonoscopy at the time because of an inadequate bowel prep. The record indicates that the enrollee 
has signs and symptoms of esophageal obstruction and a history of colonic polyps. A bowel prep is 
recommended for capsule endoscopy. The record does not establish that the requested procedure is safer and more efficacious for the enrollee than standard endoscopy at this time. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules,  of the requested service at this time. 
The elements of the coverage criteria are not satisfied. 
 
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 gastrointestinal tract imaging (capsule endoscopy) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for diagnostic services provided on February 8, 2022. 
 
You asked the Plan to reduce the cost for diagnostic services. You say that you believe the billing is excessive. 
You say that if you had known the cost, you would not have had the procedure done. The Plan denied your 
request. The Plan says the cost share applied 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 there is a $500 
deductible which applies to medical supplies from an out-of-network provider. Your contract with the Plan 
clearly says that you must pay $40% coinsurance, after your $500 Plan deductible, for each out-of-network 
Medicare-covered diagnostic procedure and test.  
  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to medical supplies from an out-of-
network provider This cost sharing is a contractual obligation that had not been met at the time the diagnostic 
services were received on February 8, 2022. Therefore, $500 has been applied to meet your deductible. 
 
Since your $500 deductible has been met, you have also been asked to pay $738.31, which is 40% of the 
allowed amount for the diagnostic services. The total amount you owe is $1,238.31 ($500 deductible + $738.31 
coinsurance = $1,238.31). 
 
Service Allowed Amount Out-of-Network Coinsurance Member Liability 
Medical Supply $83.76 40% $33.50 
Regadenoson Injection $245.16 40% $98.06 
Stress Test $36.23 40% $14.49 
Myocardial Imaging $1480.64 40% $592.26 
TOTAL:   $738.31 
 
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 reduce the cost for the diagnostic services provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and 
comprehensive oral evaluation (D0150) provided on March 31, 2022. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and comprehensive oral evaluation. You say 
that according to the policy, you are allowed two preventive visits per year. You also say that you had to 
change dentists because you moved. The Plan denied your request. The Plan says the first intraoral periapical 
x-ray is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral evaluation 
exceeds the frequency limitation in 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, first intraoral periapical x-ray (D0220) 
is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is 
limited to one procedure every three plan years. The record shows that you received a comprehensive oral 
evaluation (D0150) on July 12, 2021, and your comprehensive oral evaluation (D0150) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray 
(D0220) and comprehensive oral evaluation (D0150) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and periodontal 
maintenance (D4910) provided on December 15, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test and periodontal maintenance. You say that the 
Plan provided false information to the provider saying you still had $1,000 of the maximum annual limit left 
for the 2021 plan year. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test is not a 
covered benefit under your dental plan. The Plan also says you have exhausted the annual maximum of $1,500 
that has been set in the subscriber agreement. 
 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, adjunctive pre-diagnostic test is not 
among those covered under this benefit. The contract says that the Plan offers a $1,500 annual dental benefit 
maximum. The Plan contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on September 23, 2021, and your annual maximum benefit has been exhausted Therefore, we 
decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and periodontal 
maintenance (D4910) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two custom fabricated abutments (D6057 x2), two implant supported porcelain/ceramic 
crowns (D6065 x2), and an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments, implant supported 
porcelain/ceramic crowns, and occlusal guard. The Plan denied your request. The Plan says these services are 
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 Plans 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two custom fabricated abutments 
(D6057 x2), two implant supported porcelain/ceramic crowns (D6065 x2), and an occlusal guard (D9944).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cold laser therapy. 
 
You asked the Plan to pre-approve cold laser therapy. You say that your infection is not decreasing with the 
treatment currently being provided but is slowly spreading. The Plan denied your request. The Plan says cold 
laser therapy is not a standard treatment for toenail fungal infection. The Plan says that there is not enough 
proof that shows the safety and/or success of cold laser therapy when used for this reason. 
 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 cold laser therapy. Our reviewer says 
that cold laser therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found It is well established in the medical documentation that this patient is suffering with 
onychomycosis to the right hallux and fifth digits bilaterally.  They are currently utilizing formulas three 
topical antifungal treatments without resolution.  The patient requests cold laser therapy to treat their toenail 
fungus.  Cold laser therapy is an unproven and certainly experimental modality for the treatment of 
onychomycosis.  A review of the current medical literature does not reveal a double-blind placebo-controlled 
study demonstrating significant efficacy of cold laser therapy on toenail fungus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cold laser therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cold laser therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services, advanced life support (ALS), emergency 
transport (A0427-QL) billed for date of service, January 16, 2022. 
 
You asked the Plan to pay for ambulance services billed at the ALS rate. You say that this claim was denied in 
error. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare 
guidelines. 
 
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 rules say that for ambulance services, in a 
case where the time of death pronouncement was made before dispatch, no payment is made. In a case where 
the time of death pronouncement is after dispatch but before the beneficiary is loaded onboard the ambulance 
(before or after arrival at the point of pickup), the provider's/suppliers Basic Life Support (BLS) base is paid 
(no mileage or rural adjustment). The QL modifier must be used when submitting the claim. 
 
We find that CPT code A0427-QL is not supported in the medical record. Specifically, A0427 is the ALS rate 
for emergency ambulance transportation rather than the BLS rate. Based on this information, we decided that 
Medicare rules for billing ambulance services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services, advanced life support (ALS), emergency transport (A0427-QL) billed for 
date of service, January 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic crowns on teeth #3, #4, #8, #13, #14, #15, 
abutment crowns for tooth #2, #5, #7, #9, and #12, buildups on teeth #2, #7, #9, a crown for tooth #2. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says a maxillary partial denture will help restore normal masticatory function. 
 
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 the dental 
services 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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found that 
the requested treatment is not medically necessary. The request has been made for a long span bridge from 
tooth #2-15, replacing teeth #s #3, #4, #8, #13, #14, #15. There is an existing bridge from #7-9 which appears 
to be intact and without caries. Tooth #2 has significant bone loss and would be a questionable abutment tooth. 
#3 and #15 would require extraction for the treatment plan to be viable, which was not indicated on the 
authorization form. The bridge from #7-9 would have to be replaced despite being intact in order to perform the 
requested services. The periodontal condition of #2 would preclude the use of that tooth as a viable abutment for a long span bridge. The placement of a fixed prosthetic appliance will only be considered for those 
exceptional cases where there is a documented physical or neurological disorder that would preclude placement 
of a removable prosthesis. In this case there has been no showing of any disorder that would preclude the use of 
a removable appliance. This, in addition to the inadequacy as an abutment of tooth #2, would make the bridge, 
pontics, core buildups not medically necessary in this case. A partial denture has been approved as an 
alternative treatment. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontic crowns on teeth #3, #4, #8, #13, #14, #15, abutment crowns for tooth #2, #5, #7, 
#9, and #12, buildups on teeth #2, #7, #9, a crown for tooth #2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch nerve blocks. 
 
You asked the Plan to pre-approve medial branch nerve blocks. You say that medial branch nerve blocks are 
medically necessary. The Plan denied your request. The Plan says medial branch nerve blocks are not 
medically necessary. 
 
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 medial branch nerve blocks. Our 
reviewer says that medial branch nerve blocks are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that you have left sided radicular pain with a corresponding bulging disc at 
C6-C7.  This is a probable pain generator and therefore, the requested service is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch nerve blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve medial branch nerve blocks.
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 clinical documentation does not show that the member's care cannot 
be provided at a lower level. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional 
level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 
days per week with multidisciplinary approach in an IRF. While the enrollee may benefit from continued 
physical and occupational therapy, the enrollee's rehab needs can be safely provided in a lower intensity and 
alternate setting. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 8, 2021. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this procedure was medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the standard 
of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. PRC panel 
testing is considered unproven and not medically necessary. 
 
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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is an 83-year-old male with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. In this case, urine PCR amplification techniques raise considerable concerns 
regarding contamination from one specimen to another, creating the potential for false-positive results. The 
clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent 
infection or colonization cannot be distinguished from active, clinically significant infections.  Additionally, 
PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the 
clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR 
have not been reported in large groups of patients for many of the microorganisms. Therefore, the provided 
testing was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on June 8, 
2021.