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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78608). 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the records do not 
support that the enrollee meets diagnostic criteria for both Alzheimer's disease (AD) and frontotemporal 
dementia. The Plan also says the records do not indicate concern for frontotemporal dementia, so does not 
support evaluation with a PET/computed tomography. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found there are no clinical findings to suspect 
frontotemporal dementia after extensive testing listed in the NCD. Your clinical presentation does not meet the 
guideline criteria for the requested imaging study. Our reviewer found that you do not have a condition which 
is indicated for coverage. Our physician reviewer also found that there are not any limitations as listed in the 
NCD that would prevent coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan (78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from January 4, 
2022, to January 7, 2022, billed with diagnosis related group (DRG) code 177. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 177. You say that the enrollee 
was monitored, evaluated, and managed utilizing significant hospital resources, hence respiratory failure, 
unspecified with hypoxia was appropriately coded as the secondary diagnosis. You also say that payment 
should be approved for the originally billed DRG 177. The Plan denied your request. The Plan says DRG 177 
is not supported as the diagnosis of Respiratory failure, unspecified with hypoxia. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.91, defined as 
Respiratory failure, unspecified with hypoxia. 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 inpatient hospital services billed with DRG 177. Our reviewer says that the submitted DRG is not 
supported. Our physician reviewer found the enrollee presented to the hospital with a syncopal episode with 
cough and shortness of breath related to COVID-19 infection. The enrollee was febrile with oxygen saturation 
of 98% on room air and respiratory rate of 13 with normal blood pressure and pulse. Our reviewer found that 
the enrollee did not require steroids or oxygen support during this admission. Our physician reviewer also 
found that the medical records, therefore, do not support the billing of respiratory failure, unspecified with 
hypoxia with DRG 177.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from January 4, 2022, to January 7, 2022, billed with diagnosis 
related group (DRG) code 177.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
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 that the services you need can be provided safely 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 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 found to be medically reasonable and necessary for this enrollee. Hip fracture is an IRF 
compliant diagnosis. Clinical documentation shows that you have multiple active comorbidities and would be 
expected to require lose medical supervision on an inpatient basis. Evaluating therapists recommend intense 
therapy thus IRF criteria has been met and is medically necessary. Our physician reviewer found that your 
condition meets 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 core buildups, including any pins when required 
(D2950) for tooth #'s 20, 28, and 29 and crowns (D2752) for tooth #'s 20, 28, and 29. 
 
You asked the Plan to pre-approve the core buildups and crowns. You say that treating tooth #'s 20, 28, and 29 
with buildups and crowns will not only restore the integrity of the tooth structure, but also provide a long-term 
prognosis which will alleviate the enrollee of sensitivity and pain. The Plan denied your request. The Plan says 
these services are not medically necessary because the enrollee's teeth are not healthy because of large cavities 
or poor bone around their teeth. 
 
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 core 
buildups and crowns 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 core buildups and crowns. Our 
reviewer says that the requested services are not reasonable or necessary. Our physician reviewer found tooth 
#20 is not maintainable in the dental arch and would not be a candidate for a core buildup and crown. Tooth #'s 
28 and 29 both have occlusal and facial wear that is amenable to restoration with a standard composite 
restoration, with a maximum of two involved surfaces per tooth. Our physician reviewer also foudn that given 
that tooth #20 is not salvageable, and both tooth #'s 28 and #29 are minimally involved structurally, core 
buildups and crowns would not be found to be meeting the Plan criteria. 
 
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 core buildups and crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core buildups, including any pins when required (D2950) for tooth #'s 20, 
28, and 29 and crowns (D2752) for tooth #'s 20, 28, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 01, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests received on May 16, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that the tests you purchased meet all of the 
requirements for reimbursement. The Plan denied your request. The Plan says over the counter COVID-19 
testing kits are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that COVID-19 tests will be covered outside of your 
existing plans coverage. You can get over-the-counter COVID-19 tests at any pharmacy or health care 
provider that participates in this initiative. Enrollees cannot submit a claim for these tests to Medicare or their 
MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative. The participating 
provider would bill Medicare directly for reimbursement of the tests provided to the enrollee.  
 
 We looked at the file and Medicare rules. Review of the file shows that you did not receive these COVID-19 
tests from a pharmacy or health care provider that participates in the test initiative. This means you cannot be 
reimbursed for the tests received. Based on this information, we decided that Medicare rules for coverage of the 
COVID-19 tests have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-
19 tests received on May 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 You asked the Plan to pre-approve 12 additional PT visits. You say that the requested physical therapy services 
are medically necessary. The Plan denied your request. The Plan says additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 12 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The reviewer also found that the records do not demonstrate 
that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational 
therapy, by or under the supervision of a therapist. Therefore, the reviewer found that the additional visits are 
not 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 12 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the pelvis (72195) 
provided on April 25, 2022. 
 
You asked the Plan to pay for the MRI. You say that not getting prior authorization was a failure on the part of 
the provider. You also say if they had told you it was not going to be approved, you would not have gotten the 
MRI. The Plan denied your request. The Plan says this service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for the MRI. Our reviewer says that the MRI 
was not reasonable and necessary. Our physician reviewer found the detailed documentation is not evident 
regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. 
Additionally, you have pain noted in the low back with radiation of pain, as well as left hip pain. Our reviewer 
found that the documentation does not reveal any significant objective deficits that require immediate imaging 
prior to conservative measures, including physical therapy and/or physician-directed exercises. Our physician 
reviewer also found that there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for the magnetic resonance imaging (MRI) of the pelvis (72195) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
29, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for physician/practitioner services, including doctors office visits. 
 
 
 
 
 
 
 
 You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 copayment for a specialist office visit provided on June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Durolane, Monovisc, or Synvisc-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer-cast metal for a resin bonded fixed prosthesis 
(D6545) provided on February 24, 2022. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy. 
 
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, this item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer-cast metal 
for a resin bonded fixed prosthesis (D6545) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 billed for date of service June 4, 2021. 
 
You asked the Plan to pay for procedure code 99211. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99211 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99211 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99211 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99211 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99211 billed for date of service June 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 continued physical therapy (PT) services. 
 
You asked the Plan to pre-approve continued PT services. You say that you feel the enrollee would benefit 
from additional therapy. The Plan denied your request. The Plan says there is no clinical evidence to support 
the medical necessity of this examination or that the enrollee meets Medicare criteria for continued PT services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 continued PT services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found there is no documentation that the requested therapy is 
generally accepted as specific and effective therapy for the enrollee's condition. Our reviewer found that there 
is no documentation that the unique skills of a professional therapist are required to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist or under the 
supervision of a therapist. Our physician reviewer also found that there is no documentation that the specialized 
skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program 
to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued PT services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 continued physical therapy (PT) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit on February 7, 
2022, and an office visit on May 25, 2022. 
 
You asked the Plan to waive the copayments for an emergency room visit and an office visit. You say that you 
should not be responsible to pay this. The Plan denied your request. The Plan says the cost share has been 
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 you must pay a $90 
copayment per emergency room visit. Your contract with the Plan also clearly says that you must pay a $15 
copayment for in-network PCP office visits/other healthcare professionals.  
 
 
 
 You have been asked to pay $105 ($90 + $15 = $105) for an emergency room visit and an office visit. An 
emergency room visit falls within the Emergency Care benefit category. An office visit falls within the 
Physician/Practitioner Services, Including Doctors 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 an emergency room visit on February 7, 2022, and an office visit on May 25, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the decompression fasciotomy services coded 27602 
provided on June 4, 2021. 
 
You asked the Plan to pay for the decompression fasciotomy services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 27602 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of Decompression fasciotomy, leg; anterior and/or lateral, and posterior 
compartment(s); therefore, the billed service cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the decompression fasciotomy services have not been met.  Therefore, we decided that the Plan does not have to pay for the decompression fasciotomy services coded 
27602 provided on June 4, 2021.