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

 
We decided that the Plan does not have to pre-approve GeneSight Psychotropic Panel genetic testing. 
 
You asked the Plan to pre-approve GeneSight Psychotropic Panel genetic testing. You say that the requested 
GeneSight Psychotropic Panel is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the GeneSight Psychotropic Panel. 
 
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 GeneSight Psychotropic Panel genetic 
testing. Our reviewer says that the enrollee does not meet criteria for the GeneSight Psychotropic Panel. Our 
physician reviewer found the enrollee has major depressive disorder and anxiety. GeneSight Psychotropic 
Panel (genetic testing) was requested. However, this testing was ordered to help decide what drugs to consider 
for treatment of the enrollee's condition rather than to modify current medication treatment, and, therefore, does 
not meet requirements for Medicare coverage based on the LCD criteria. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight Psychotropic Panel genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve GeneSight Psychotropic Panel genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87640, and 87653 billed for 
date of service July 14, 2021. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87640, and 87653. You say that you have 
provided documentation to support payment for each code. The Plan denied your request. The Plan says 
payment for codes 87798, 87481, 87640, and 87653 is bundled into the payment for code 87801. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87798, 87481, 87640, and 87653 are column II codes to column I code 87801. This claim has not been billed 
with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87481, 
87640, and 87653 billed for date of service July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthovisc.  
You asked the Plan to pre-approve orthovisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you're currently being considered for a full or partial knee replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that orthovisc can be covered if Medicare criteria has 
been met. 
 
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 orthovisc. Our reviewer says that 
orthovisc is not considered medically reasonable and necessary in this case. You have knee pain but do not 
indicate that the symptoms interfere with the activities of daily living such as ambulation and prolonged 
standing, or pain interrupting sleep, crepitus, and/or knee stiffness. There is no objective radiologic evidence of 
osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral 
cysts. There are no objective physician medical progress notes indicating that other diagnoses have been 
excluded by appropriate evaluation and management services, laboratory and imaging studies. The 
documentation does not reveal that you have failed at least three months of conservative therapy. There are no 
objective medical progress notes indicating there was failure of aspiration of the knee when an effusion was 
present and failure of intra-articular corticosteroid injection therapy when inflammation is a significant 
component of your symptoms and intra-articular corticosteroids are not contraindicated. An authorization 
protocol on March 30, 2022 notes that knee arthroplasty is considered treatment option for you. Our physician 
reviewer found that your condition does not meet Medicare criteria for orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), 
extraction (D7210), incision and drainage of abscess (D7510), unspecified preventive service (D1999), and 
sedation (D9222, D9223) provided from November 19, 2021, to November 29, 2021, by the out of network 
provider. 
 
You asked the Plan to pay for the dental services. You say that tooth extractions are covered. You say that you 
were advised this plan covered all that Medicare does plus all the extras that the plan provides. You also say 
that you feel these services should be covered. The Plan denied your request. The Plan says detailed and 
extensive oral evaluation, incision and drainage of abscess, unspecified preventive service, and sedation are not 
listed as covered services. The Plan says that the provider in this case is out of network. The Plan also says that 
extractions are not covered when you receive them out of network. 
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 and extractions are listed as covered, 
you pay 100% for this service when received out of network. Additionally, the detailed and extensive oral 
evaluation, incision and drainage of abscess, unspecified preventive service, and sedation are not among those 
covered under this benefit regardless of the provider's network status. Therefore, we decided that the Plan does 
not have to pay for the detailed and extensive oral evaluation (D0160), extraction (D7210), incision and 
drainage of abscess (D7510), unspecified preventive service (D1999), and sedation (D9222, D9223) provided 
from November 19, 2021, to November 29, 2021, by the out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an application of skin substitute graft (15275). 
 
You asked the Plan to pre-approve an application of skin substitute graft. You say that the requested service is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules 
for the requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 application of skin substitute graft. 
Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our 
physician reviewer found that the wound is nonhealing and has been nonhealing for greater than 3 and a half 
months. The enrollee has undergone appropriate conservative care including numerous wound debridements. 
 
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 application of skin substitute graft have been met. Therefore, we decided that 
the Plan has to pre-approve an application of skin substitute graft (15275).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a neurology specialist office visit provided 
on November 9, 2021. 
You asked the Plan to waive the copayment for a neurology specialist office visit. You say that you should not 
have to pay that much for the office visit because the provider does not do much when you go in. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for an in-network specialist office visit.  
 
You have been asked to pay a $30 copayment for a neurology specialist office visit. A neurology specialist 
office visit falls within the Physician/Practitioner Services, Including Doctor's 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 neurology specialist office visit provided on November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided on October 16, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no 
work component associated with this service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99153 is a technical component only code. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for moderate sedation services provided on October 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and prophylaxis 
(D1110), provided on October 26, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you have exceeded the maximum frequency limit set for these services. 
 
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 pay for the 
periodic oral evaluation (D0120), and prophylaxis (D1110), provided on October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF transfer. The Plan denied your request. The Plan says the SNF 
services you are requesting do not meet the requirements for approval. 
 
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 the SNF transfer. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve a transfer 
to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retrograde filling (D3430), apicoectomy (D3410), and 
bone replacement graft (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are medically 
necessary. You also say that you have an infection. The Plan denied your request. The Plan says the services 
are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested retrograde filling, 
apicoectomy, and bone replacement graft are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve retrograde filling (D3430), apicoectomy (D3410), and bone 
replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implant (D6010) and cone beam computed 
tomography (CT) (D0367) provided from August 5, 2021, to August 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised the services were covered at 
50%. You say that the provider office confirmed this with the plan. You also say that you should not have to 
pay more. The Plan denied your request. The Plan says the implant and cone beam CT are not listed as covered 
services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the implant and cone beam CT are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
endosteal implant (D6010) and cone beam computed tomography (CT) (D0367) provided from August 5, 2021, 
to August 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428-HN), 
ground mileage (A0425-HN), and supplies (A0382-HN) provided on September 27, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported to the hospital 
multiple times on the same date of service. You also say that the services should be covered. The Plan denied 
your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation did 
not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on September 27, 2021. The documentation did not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport on September 27, 2021. The reviewer also found that the 
documentation did not support that the ambulance transport on September 27, 2021 was medically reasonable 
and necessary for the enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428-HN), ground mileage (A0425-HN), 
and supplies (A0382-HN) provided on September 27, 2021.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. All medically necessary care is being provided in the current acute care facility. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), provided on November 
17, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that the service should be covered. The 
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency 
limits 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge comprised of false teeth (D6240) and 
retainer crowns (D6750) for teeth #18-#21. 
 
You asked the Plan to pre-approve the dental bridge. You say that these services are necessary. The Plan 
denied your request. The Plan says the bridge in this case is requested to replace two back teeth. Your dental 
benefit only covers fixed bridges for one missing upper front tooth or up to two missing, adjacent lower front 
teeth.  
 
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. The Plan dental bridges when 
they are provided to replace either one upper front tooth or two adjacent missing lower front teeth. We looked at the file and the Plan's rules. The request in this case is for a four-unit bridge designed to replace teeth #19 and #20, which are defined as posterior (back) teeth. The Plan only offers coverage for missing anterior (front) teeth and only under certain conditions. Bridges to replace missing back teeth are not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the dental bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental bridge comprised of false teeth (D6240) and retainer crowns (D6750) for teeth #18-#21.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 hyperbaric oxygen (HBO) therapy sessions. 
 
You asked the Plan to pre-approve 33 additional hyperbaric oxygen (HBO) therapy sessions. You say that the 
requested services are necessary. You say that there was a mistake in requesting units for the chamber itself. 
You say that an additional 160 units, approximately 4 units per visit are necessary. You also say that the 
services are necessary. The Plan denied your request. The Plan says additional treatment would be reconsidered 
upon medical documentation noting HBO therapy is showing improvement with wound healing. 
 
The Plan follows Medicare rules. Medicare rules say that continued treatment with HBO therapy is not covered 
if measurable signs of healing have not been demonstrated within any 30-day period of treatment. 
 
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 33 additional hyperbaric oxygen (HBO) 
therapy sessions. Our reviewer says that 33 additional hyperbaric oxygen (HBO) therapy sessions are not 
medically necessary. Our physician reviewer found the provided documentation does not support that the 
enrollee has completed the approved 7 sessions showing benefit from the HBO to support additional sessions 
beyond the 7 approved. Therefore, without sufficient support made for this request, the remaining 33 sessions 
of HBO 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 33 additional hyperbaric oxygen (HBO) therapy sessions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 40 hyperbaric oxygen (HBO) therapy 
sessions.