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

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing provided on February 14, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test eligible for Medicare 
coverage. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. They argue that since this panel 
includes that specific gene, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing 
provided on February 14, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 1, 2020, through February 28, 2020, and billed with Patient-Driven Payment Model (PDPM) score of 
GDKD1. 
 
You asked the Plan to pay for the SNF care as billed. You say that the medical record supports payment for the 
SNF care as it was billed. The Plan denied your request. The Plan says the reported PDPM code of GDKD1 is 
not supported in the medical records provided. Rather, PDPM code PDYF1 is more appropriate in this case for 
the SNF services rendered. 
 
The Plan follows Medicare rules. Medicare rules say that all skilled nursing facility (SNF) Part A inpatient 
services are paid under a prospective payment system (PPS). This involves payment based on a Health 
Insurance Prospective Payment System (HIPPS) rate code. Under the new Patient-Driven Payment Model 
(PDPM), which is effective for services provided on or after 10/1/2019, the HIPPS code is structured 
differently, as a result of there being five case-mix adjusted rate components under the revised model. 
 
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 SNF care as billed. Our reviewer says 
that the documentation does not support payment for the SNF care is billed with a PDPM score of GDKD1. 
Our physician reviewer found the enrollee is a 57-year-old man with a diagnosis of unspecified fracture of 
unspecified pubis, subsequent encounter for fracture with routine healing. The medical history includes 
multiple sclerosis, chronic obstructive pulmonary disease, gastroesophageal reflux disease, dementia, and 
anemia. An MDS Resident Assessment and Care Screening form is dated January 8, 2020. In this case, the 
medical record does not contain documentation supporting the enrollee's usual functional abilities. 
Consequently, the plan has appropriately used a default score and changed the first digit in the PDPM from a G 
to a P. In addition, the case file does not contain sufficient documentation of a nursing function score. 
Therefore, the Plan has correctly adjusted the third digit in the PDPM from a K to a Y. Based on these scores, 
the fourth digit in the PDPM will automatically change to a F. The documentation does not support payment 
for the SNF care as billed with a PDPM score of GDKD1. 
 
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 SNF care as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) care provided from February 1, 2020, through 
February 28, 2020, and billed with Patient-Driven Payment Model (PDPM) score of GDKD1.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Orencia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Remicade, Inflectra, infliximab, or Simponi Aria and has tried or cannot use Stelara before they will 
approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plans required drug(s) would likely be less effective and/or likely 
have adverse effects 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry testing (83789) provided alongside drug 
testing services on October 13, 2021. 
 
You asked the Plan to pay for code 83789. You say that these services were billed appropriately. The Plan 
denied your request. The Plan says they have agreed to pay for the drug testing services; however, specimen 
validity testing 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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for mass spectrometry testing (83789) provided alongside drug testing services on October 13, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of soft tissue localization device (10035) 
provided on October 22, 2021. 
 
You asked the Plan to pay for the placement of soft tissue localization device (10035). You say that the 
appropriate modifier was appended to show it is a distinct and separate service. You say that the report shows 
the services were provided and the claim should be adjusted for payment. The Plan denied your request. The 
Plan says procedure codes 19083, 38505 and 76942 have been overturned. The Plan also says procedure code 
10035 is inclusive to procedure code 19083 and cannot be separately reimbursed. 
 
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 code 10035 is a column II code to column I code 19083; however, 10035 
was billed with a modifier.  
 
We asked our coder 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 placement of soft tissue localization device (10035). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the procedure report does not support the placement of soft tissue localization device was 
separate from the breast biopsy with placement of breast localization device. In this case, CPT code 10035 is 
included in CPT code 19083 and modifier -59 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the placement of soft tissue localization device (10035) have not been met. 
Therefore, we decided that the Plan does not have to pay for the placement of soft tissue localization device 
(10035) provided on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards (K0108). 
 
You asked the Plan to pre-approve side guards. You say that these items are medically necessary. The Plan 
denied your request. The Plan says these items do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve side guards (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown (D2799).  
 
You asked the Plan to pre-approve the interim crown. You say that a crown is the best treatment option for the 
enrollee. The Plan denied your request. The Plan says the crown is not a covered service under the enrollee's 
benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim crown (D2799).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of an autologous blood 
concentrate product (D7921). 
 
You asked the Plan to pre-approve the dental service. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the collection and application of an autologous blood 
concentrate product (D7921) is not covered by your dental 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 the 
collection and application of an autologous blood concentrate product (D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #27 and 30 (D6740) and a 
pontic on tooth #29 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you were told these services would be 
covered. The Plan denied your request. The Plan says retainer crowns (D6740) and pontics (D6245) are not 
covered by your routine dental 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 
retainer crowns on tooth #27 and 30 (D6740) and a pontic on tooth #29 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260), bone replacement graft  
retained natural tooth (D4263), and guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the surgery, bone replacement graft, and tissue regeneration. You say that 
you are in a lot of pain and cannot sleep at night. The Plan denied your request. The Plan says these services 
are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260), bone replacement graft  retained natural tooth (D4263), and guided tissue 
regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures do not fit on your 
mouth and you need them fixed. 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 complete denture  maxillary (D5110) and complete denture  mandibular (D5120) 
were both exhausted on date of service October 25, 2021. Therefore, we decided that the Plan does not have to 
pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services for the enrollee. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that this surgery is not designated by Medicare for inpatient only 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our reviewer 
says that inpatient hospital services are not medically reasonable and necessary. The record provided does not 
indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights, taking into account complex medical factors. The initial day may be spent in observation until it is 
clearly expected that a second midnight would be required, at which time the physician may order inpatient 
admission. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two denture relines and replacement of missing or 
broken teeth - complete denture. 
 
You asked the Plan to pre-approve the dental services. You say that you have lost so much weight from your 
heart surgery, your dentures do not fit properly. The Plan denied your request. The Plan says you can have the 
upper or lower denture relined since one reline is covered per year. The Plan also says the replacement of 
replace missing or broken teeth - complete denture (D5520) is not a covered benefit. 
 
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. A denture 
reline is limited to one per calendar year and your benefit will be exhausted with the reline of one of your 
dentures. In addition, the replacement of missing or broken teeth - complete denture (D5520) is not listed as a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve two denture relines and the 
replacement of missing or broken teeth - complete denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that this service is not covered 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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve splint  extra-coronal; natural teeth or prosthetic crowns 
(D4323). 
 
You asked the Plan to pre-approve an extra-coronal splint. You say that this service is necessary. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's 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 
splint  extra-coronal; natural teeth or prosthetic crowns (D4323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820). 
 
You asked the Plan to pre-approve the interim partial denture. You say that you would like this service covered 
because it is medically 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 the 
interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction (D7210) for teeth # 9, 10 and 11. 
 
You asked the Plan to pre-approve the dental services. You say that you need 6 teeth extracted. You say that 3 
were denied. You say that you need these teeth extracted so you can get a denture. You also say that you cannot 
afford to pay $600 for the 3 extractions. The Plan denied your request. The Plan says your benefit for the 
requested surgical extractions has already 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, certain limitations apply. The record 
shows your benefit for the requested surgical extractions has been reached. The record shows that the Plan approved surgical extractions for teeth # 6, 7 and 8. Therefore, we decided that the Plan does not have to pre-
approve surgical extraction (D7210) for teeth # 9, 10 and 11.