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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 4, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), panoramic radiographic image (D0330), prophylaxis - adult (D1110), resin-based composite - three 
surfaces, anterior (D2332), and resin-based composite - four or more surfaces (D2335) provided on July 26, 
2022 to August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand the bills you received 
and were told by the dentist he is out-of-network so the charges are your responsibility. The Plan denied your 
request. The Plan says the out-of-network liability was applied correctly per your Plan benefits. 
 
 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, when services are obtained from an 
out-of-network dentist the Plan only pays up to a certain amount. You are responsible for any amount beyond 
what the Plan pays.  
 
Therefore, we decided that the Plan does not have to pay for the dental services provided on July 26, 2022 to 
August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on July 19, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that no explanation was given as to why this claim was 
denied. The Plan denied your request. The Plan says you purchased these hearing aids from an out-of-network 
provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use a Plan-approved hearing provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve an MRI of the abdomen. You say that the records provided support the need 
for the requested MRI. The Plan denied your request. The Plan says the requested MRI is 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 pre-approve an MRI of the abdomen. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found Appellant reports right 
upper quadrant (RUQ) pain, but recent computed tomography (CT) imaging showed no acute pathology, no 
liver masses, and a surgically-absent gallbladder.  No laboratory data was provided, and no red flags were 
identified on provided abdominal exam.  The enrollee's record notes a history of irritable bowel syndrome 
(IBS) without recent change in bowels, and fatty liver with no significant fibrosis. MRI imaging as requested is 
not medically appropriate nor necessary at this time in the absence of suspicious findings on imaging, 
laboratory, or physical exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve swingaway, retractable, or removable hardware (E1028). We 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).   
You asked the Plan to pre-approve swingaway, retractable, or removable hardware (E1028) and a power seat 
elevation feature (E2300). You say that these items are medically necessary. The Plan says that these items are 
not necessary. 
 
We decided that the Plan has to pre-approve swingaway, retractable, or removable hardware (E1028).  
 
The Plan must follow Medicare rules. The rules say one example (not all-inclusive) of a covered indication for 
swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so 
that a beneficiary can perform a slide transfer to a chair or bed.   
 
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 swingaway, retractable, or removal 
hardware (E1028). Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing his basic daily activities. The swingaway, retractable, or removable 
hardware is needed to operate the power wheelchair and allow the enrollee to transfer to and from it. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of swingaway, retractable, or removable hardware (E1028) have been met. 
Therefore, we decided that the Plan has to pre-approve swingaway, retractable, or removable hardware 
(E1028).  
 
We also decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
The Plan must follow Medicare rules. The rules say a power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature (E2300). 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 respiratory failure and COVID infection. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of IRF services is correct. 
 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may need physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services.  Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), and 
panoramic radiographic image (D0330) provided on April 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you shouldn't have to pay because the 
provider did not discuss what he was going to do and additional x-rays were done. The Plan denied your 
request. The Plan says your benefit for the requested items or services are not covered or have 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 August 30, 2022, 
processing before the claim for the services at issue. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), and 
panoramic radiographic image (D0330) provided on April 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee continues to have medical conditions 
that benefit from the continuous monitoring of skilled rehabilitation physicians and nurses. The Plan denied 
your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as home with supervision and home health services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on 
September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to find a new in-network provider; 
therefore, this service should be covered. 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. This benefit includes the 
requested panoramic radiographic image (D0330) but is limited to one procedure every three plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested panoramic radiographic image (D0330) was exhausted on date of service 
February 23, 2021. Therefore, we decided that the Plan does not have to pay for panoramic radiographic image 
(D0330) provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 28, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to be able to go home in 7 to 10 days and 
that will not happen without admission to an IRF. The Plan denied your request. The Plan says the denial of 
IRF services is correct. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
September 13, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not told this would not be covered before 
you made my decision. The Plan denied your request. The Plan says this service is not covered under your 
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. Periodontal scaling and root 
planing (D4342) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal scaling and 
root planing (D4342) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling and root planing (D4342) provided on September 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 3, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 $350 
copayment for outpatient surgery/endoscopy.  
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/endoscopy 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 an 
outpatient surgery provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the records provided support the need 
for the CardioMEMs device. The Plan denied your request. The Plan says the requested CardioMEMs device is 
considered experimental/investigational. The Plan says that there are not enough medical studies to show that 
this device helps the enrollee's condition. 
 
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 a CardioMEMs device. Our reviewer 
says that a CardioMEMs device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found a CardioMEMs device. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Rifton Tram lift. 
 
You asked the Plan to pre-approve the Rifton Tram lift. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says that the code (E1399) in this request is not a 
code recognized by Medicare for walkers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has inappropriately denied this preservice request based on 
the codes that will be billed. We therefore requested the Plan reach out to the enrollees provider for additional 
medical records that indicate the medical necessity of the requested equipment. A response to our request for 
information was not received. Therefore, we decided that the Plan has to pre-approve the Rifton Tram lift.  
 
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.