Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a cardioversion procedure (92960) provided on November 6, 2021. 
 
You asked the Plan to pay for a cardioversion. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the submitted medical records support that the service at issue was 
rendered by the billing physician. It is the responsibility of the Plan to substantiate its denial. The denial has not 
been substantiated in this case so we must find in your favor. Therefore, we decided that the Plan has to pay for 
a cardioversion procedure (92960) provided on November 6, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast 
including computer-aided detection (CAD) for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the evidence does not suggest improved outcomes for this request. 
 
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 the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the enrollee's breast 
density on mammography was characterized as scattered fibroglandular elements which means it is not 
extremely or heterogenously dense. The prior MRI showed intact implants, and while not done with contrast, 
showed no disturbing findings. There is no documented increased risk of breast cancer using the Gail or Tyrer-
Cuzick models. There is no physical exam of the breasts in the records. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the breast including computer-aided detection 
(CAD) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation via a vertical approach (D7952). 
 
You asked the Plan to pre-approve sinus augmentation. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered under your 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, 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 sinus 
augmentation via a vertical approach (D7952).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis and a urinary tract 
infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive 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. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) device (K0554) and 
related supplies (K0553) provided on October 29, 2021. 
 
You asked the Plan to pay for a CGM and related supplies. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is no evidence in the available medical records that the provider discussed the 
need for the billed supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) device 
(K0554) and related supplies (K0553) provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided are neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 29, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 months of oxygen equipment rental 
(E0431, E1390). 
 
You asked the Plan to pre-approve an additional 6 months of oxygen equipment rental. You say that 6 months 
of additional rental is medically necessary. The Plan denied your request. The Plan says 12 months of oxygen 
rental has already been approved. A recertification is required at the end of the approved 12 months before an 
additional 6 months can be considered. 
 
The Plan must follow Medicare rules. Medicare rules say that initial coverage of oxygen for beneficiaries 
meeting Group I criteria is limited to 12 months or the treating practitioner's specified length of need, 
whichever is shorter. 
 
We looked at the file and Medicare rules. Two 6 month rental periods have already been approved. A review of 
clinical records and recertification at the end of 12 months is required before an additional 6 months can be 
approved. Based on this information, we decided that Medicare rules for coverage of an additional 6 months of 
oxygen equipment rental have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an additional 6 months of oxygen equipment rental (E0431, E1390).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided by an out-of-network 
provider on November 1, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was rendered due to medical 
necessity and patient care was provided as an urgent request. You say that the physician provided services 
without authorization to avoid delay in care and the claim should be processed for payment. The Plan denied 
your request. The Plan says pre-approval is required for services that will be given by a non-contracted 
provider. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided by an out-of-
network provider on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until November 8, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rheumatology services to be provided by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve rheumatology services. You say that the specialist that you are currently 
seeing doesn't understand your condition. The Plan denied your request. The Plan says based on the rules and 
rationale, denial is being upheld. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care. 
 
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 rheumatology services. Our reviewer 
says that based on the medical records provided you do not meet the criteria for continuity of care with an out-
of-network provider. Our physician reviewer found this patients condition is not considered urgent/emergent 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rheumatologist services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve rheumatologist services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81241, 81240). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this type of genetic testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing 
for thrombophilia testing for the Factor V Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) variant in 
the F2 gene, and the MTHFR gene which encodes the 5, 10-methylenetetrahydrofolate reductase enzyme. 
Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including 
cardiovascular risk assessment, are non covered except for pregnant patients. 
 
We looked at the file and Medicare rules. The requested genetic tests are non-covered. 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 pre-approve genetic testing (81241, 81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management provided on 
November 1, 2020. 
 
You asked the Plan to pay for observation care discharge day management. The Plan denied your request. The 
Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for observation care discharge day management was not filed until  
December 16, 2021. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for observation care discharge day 
management provided on November 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral capsulectomy and implant removal. 
 
You asked the Plan to pre-approve the procedures. You say that the existing implants are problematic and 
require replacement. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 procedures. Our reviewer says that 
the requested procedures are not medically reasonable or necessary. Our reviewer found the record indicates 
that the enrollee has previously undergone breast augmentation with implants for cosmetic reasons. The 
treatment of complications from cosmetic surgery is considered cosmetic in nature. The record does not 
indicate the presence accidental injury or presence of a malformed body member. The record does not indicate 
a breast cancer diagnosis. 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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral capsulectomy and implant removal.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 acute care hospital. 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 while the patient has a need for physical and occupational therapy, there is no 
documentation of a need for an intensive inpatient 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (27447) provided on October 4, 2021. 
 
You asked the Plan to pay for the service. The Plan denied your request. The Plan says the MUE value was 
exceeded.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 27447 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
service have not been met. Therefore, we decided that the Plan does not have to pay for the services (27447) 
provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SSC testing provided on November 12, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this testing method has insufficient high quality data to support its use over using standard treatment 
guidelines for skin cancer to support its use and show superior overall outcomes over standard of care. As it is 
somewhat experimental in use for the enrollee's current clinical situation, the requested DecisionDX-SSC will 
be considered not medically necessary at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the DecisionDX-SSC testing provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. You say that the other 
side of your tooth was already impacted. You also say that you are having a hard time chewing. The Plan 
denied your request. The Plan says crowns are limited to once per tooth every 5 years. The Plan also says that 
the frequency limit has been reached. 
 
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 and crowns are limited to once per 
tooth every 5 years, the frequency limit has been reached. The record shows that the Plan paid for a crown for 
tooth # 30 that you received on January 9, 2019. Therefore, we decided that the Plan does not have to pre-
approve a porcelain crown (D2740) for tooth # 30.