Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HH physical therapy visits (CPT code G0151 x5) 
and HH occupational therapy visits (CPT code G0152 x4). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health services. Our physician 
reviewer found the health plans denial should be upheld. The enrollee does not have documented ongoing, 
skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, 
the requested, ongoing, HH skilled therapy is not medically necessary or reasonable. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the HH physical therapy visits (CPT code G0151 x5) and HH occupational 
therapy visits (CPT code G0152 x4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (coagulation factor v) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that per American Society of Hematology 
guidelines you performed a hypercoagulable workup. A routine part of this workup is genetic screening for 
Factor V Leiden mutations, which is common in the population in the USA. The Plan denied your request. The 
Plan says this service is non-covered except for pregnant patients. There is insufficient evidence in the 
published peer-reviewed scientific literature to support coverage for genetic testing for inherited 
thrombophilias outside the pregnant women as described in the LCD. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 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 F5 (coagulation factor v) (eg, hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on April 22, 2022. 
 
You asked the Plan to pay an additional amount for the eyeglasses. You say that in the past you have only had 
to pay the sales tax. The Plan denied your request. The Plan says the claim processed correctly with the $150 
annual allowance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $150 allowance.  
We looked at the file and the Plan's rules. The file shows that the Plan applied the $150 annual eyewear 
allowance to the claim. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient orthopedic services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient orthopedic services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the outpatient orthopedic services. We found no exception that would require the 
Plan to pre-approve the outpatient orthopedic services. Therefore, we decided that the Plan does not have to 
pre-approve outpatient orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
provided December 28, 2021. 
 
You asked the Plan to pay for the prefabricated post and core. You say that you would like this service covered. 
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 Plan's 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 
prefabricated post and core in addition to crown (D2954) provided December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the unspecified adjunctive procedure (D9999) provided on January 28, 2021. 
 
You asked the Plan to pay for the unspecified procedure. The Plan denied your request. The Plan says that 
they've paid the annual limit allowed by your dental plan for this benefit year. 
 
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 Plan did not submit the correct Evidence of Coverage (EOC) 
for the date of service in dispute. This means that we cannot determine what the annual limit allowed by your 
dental plan is and if it's been reached. Therefore, we decided that the Plan has to pay for the unspecified 
adjunctive procedure (D9999) provided on January 28, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided by a participating provider on April 13, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you were in a lot of pain with your tooth. You say 
that you needed the tooth extracted. The Plan denied your request. The Plan says D9215 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, 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided by a participating provider 
on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99202) echocardiogram 
(93306) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you have had decades of service from the 
requested provider and you have great confidence in their evaluations especially since they were involved in 
two personal life saving decisions in the past. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99202) echocardiogram (93306) to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided by a participating provider on March 15, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental service 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, 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided by a participating provider 
on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that these codes are valid for home health 
claims. The Plan denied your request. The Plan says the claim is missing required information/codes. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must include a line item with 
one of three Q-codes to define the location the services have been rendered. 
 
We looked at the file and Medicare rules. This claim does not include the required Q-code. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided on January 26, 
2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from April 8, 2021, to 
May 3, 2021. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that services were 
not authorized and these services are not urgent or emergent, nor were they approved in advance. 
 
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, a PPO plan does not have a lock in rule 
permitting you to only see network providers. The Plan offered no other reason to deny payment for these 
services. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided 
from April 8, 2021, to May 3, 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: 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 was in rehabilitation and had another 
stroke and needs a G-tube. The Plan denied your request. The Plan says the stay is not necessary. 
 
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 physician reviewer 
found the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive metabolic panel (80050) prothrombin time 
test (PT) (85610) thromboplastin time, partial (PTT) (85730) provided January 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that all specimens are collected at the attending 
or consulting provider office during encounter and shipped to the laboratory where tests are performed. You 
processed the accepted specimen and reported your findings back to the ordering physician for further care. 
The Plan denied your request. The Plan says 80050 is a Medicare non-covered services and 85730 and 85610 
are not covered by Medicare as a screening tool. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. The rules explicitly say that screening tests, with the exception of the few tests listed in the 
Medicare rules section, are not covered. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Medicare says a PTT may be used to assess patients with signs or symptoms of 
hemorrhage or thrombosis and a PT may be used to assess patients with signs or symptoms of abnormal 
bleeding or thrombosis. Services provided with no relation to the diagnosis and health of the patients are not a 
benefit. Therefore, PTT and PT are non-covered services. Therefore, we decided that the Plan does not have to 
pay for comprehensive metabolic panel (80050) prothrombin time test (PT) (85610) thromboplastin time, 
partial (PTT) (85730) provided January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 a comprehensive oral evaluation was exhausted on date of service June 30, 2021. The 
record also shows your benefit for intraoral x-rays was exhausted on date of service October 27, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral x-rays (D0210) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and rooting (D4341), antimicrobial agent 
(D4381), gingival irrigation (D4921), and drugs dispensed in the office (D9630), provided by a participating 
provider on March 14, 2022. 
 
You asked the Plan to pay for periodontal scaling and rooting, antimicrobial agent, gingival irrigation, and 
drugs dispensed in the office. You say that you were under the assumption that your dental office verified that 
the services provided were covered. The Plan denied your request. The Plan says these services have been 
processed correctly. 
 
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, D4381, D4921, or D9630 are not 
among those covered under this benefit. D4341 was previously provided on May 20, 2021. Therefore, we 
decided that the Plan does not have to pay for periodontal scaling and rooting (D4341), antimicrobial agent 
(D4381), gingival irrigation (D4921), and drugs dispensed in the office (D9630), provided by a participating 
provider on March 14, 2022.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, 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 services are not medically necessary. Our physician reviewer found 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 health plan has approved ongoing care in the current acute care setting. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option. You say that this 
power wheelchair is medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says the enrollee does not satisfy the coverage criteria for the group 3 power wheelchair with single power 
option. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with single power option 
is subject to the criteria listed 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 a group 3 power wheelchair with single 
power option. Our reviewer says that the requested group 3 power wheelchair with single power option is not 
medically reasonable and necessary. Our physician reviewer found the enrollee is a 53-year-old male with past 
medical history of facioscapulohumeral muscular dystrophy with mobility impairments. In this case, the 
clinical documentation specifically states that the enrollee is able to effectively pressure relief. Therefore, a 
power option is not medically necessary and a group 3 power wheelchair with power tilt/recline is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with single 
power option and accessories.