Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical and rehabilitation needs do not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care as she will not be able to make a significant functional progress in an IRF with a short stay. Documentation does not support the 
medical necessity for admission to 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is to be used for the treatment of 
restrictive thoracic disorder to morbid obesity and obesity hypoventilation syndrome (OHS). The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in VAPS mode with or without 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized with 
acute on chronic respiratory failure and improved on bipap. There is no evidence that bipap has been tried, and 
failed, at home. You do not have a diagnosis for which a home ventilator is covered, by Medicare criteria. 
There is no diagnosis of COPD. You do not have thoracic restrictive disease; obesity is not a cause of thoracic 
restrictive disease. A diagnosis of chronic inflammatory demyelinating polyneuropathy is noted, but there is no 
documentation of the neurologic deficits, and there are no pulmonary function tests showing reduction in lung 
function. You have OSA and OHS, for which the appropriate treatment is cpap or bipap. You have been 
noncompliant with home cpap in the past. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350), oral hygiene instructions (D1330) and panoramic radiographic image (D0330) 
provided January 27, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images, oral hygiene instructions and panoramic 
x-ray. You say that the receptionist told you everything would be covered. The Plan denied your request. The 
Plan says you have exceeded the frequency limit for the x-rays and the remaining services are 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. The Plan covers the complete 
series or panoramic x-ray once every 5 calendar years.   
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
x-rays was covered on the same date of service. Based on this information, we decided that the Plan's 
frequency limit for coverage of the panoramic x-ray has been exceeded. Though the Plan offers dental benefits 
in excess of Medicare coverage, the 2D oral/facial images and oral hygiene instructions are not among those 
covered services. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350), oral hygiene instructions (D1330) and panoramic 
radiographic image (D0330) provided January 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen supplies (code A0422) provided during an 
ambulance transport billed for date of service October 13, 2021. 
 
You asked the Plan to pay for the oxygen supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says no separate payment is made for these oxygen supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that the cost of oxygen and its administration in 
connection with and as part of the ambulance service is covered.  However, under the ambulance fee schedule, 
oxygen and other items and services provided as part of the transport are included in the fee schedule base rate 
and are generally not separately payable.   You have already been paid the fee schedule rate for the ambulance 
services, so no separate payment is made for the oxygen supplies provided during the transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for oxygen supplies (code A0422) provided during an ambulance transport billed for date of service October 
13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden Mutation with Rfx genetic testing. 
 
You asked the Plan to pre-approve Factor V Leiden Mutation with Rfx genetic testing. You say that the 
requested Factor V Leiden Mutation with Rfx genetic testing is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the requested Factor V Leiden Mutation with Rfx 
genetic testing. 
 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 Factor V Leiden Mutation with Rfx 
genetic testing. Our reviewer says that the enrollee does not meet criteria for the requested Factor V Leiden 
Mutation with Rfx genetic testing. Our physician reviewer found a germline hereditary mutation test, Factor V 
(F5 gene), will be considered medically reasonable and necessary when performed for evaluation of venous 
thromboembolism. In this case the enrollee has no history of venous thromboembolism. The review has 
determined that the enrollee does not meet the LCD criteria for the requested Factor V Leiden Mutation with 
Rfx genetic testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Factor V Leiden Mutation with Rfx genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Factor V Leiden Mutation with Rfx genetic 
testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration (D4265), guided tissue regeneration (D4267), and additional intraoral periapical x-ray (D0230) 
provided on December 14, 2021. 
 
You asked the Plan to pay for the biologic materials, guided tissue regeneration, and additional intraoral 
periapical x-ray. The Plan denied your request. The Plan says your Evidence of Coverage (EOC) does not 
provide a benefit for the biologic materials and guided tissue regeneration. The Plan also says that there is a 
frequency limitation regarding intraoral x-rays. 
 
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, biologic materials to aid in soft and 
osseous tissue regeneration (D4265) and guided tissue regeneration (D4267) are not among those covered 
under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. 
The record shows that you received a first intraoral periapical x-ray (D0220) on December 14, 2021 and your 
intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
biologic materials to aid in soft and osseous tissue regeneration (D4265), guided tissue regeneration (D4267), 
and additional intraoral periapical x-ray (D0230) provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the K3 microprocessor knee additions. 
 
You asked the Plan to pre-approve the K3 microprocessor knee additions. You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that overage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 K3 microprocessor knee additions. 
Our reviewer says that the items are medically necessary. Our physician reviewer found the clinical 
documentation by both prosthetist and physician state that patient is at a K3 level and requires micro-processor 
joints for variable cadence, stability and environments. 
 
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 K3 microprocessor knee additions have been met. Therefore, we decided 
that the Plan has to pre-approve the K3 microprocessor knee additions.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 considered medically reasonable and necessary in this case. 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. 
 
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 comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the services would not be 
covered. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 
plan years. The Plan says that panoramic x-ray is covered once every 3 plan years. The Plan also says that the 
frequency limits have been exceeded. 
 
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 the services are listed as covered, 
they have frequency limits of once every 3 plan years. The record shows that the Plan paid for a comprehensive 
oral evaluation that you received on August 21, 2021, and a panoramic x-ray that you received on April 1, 
2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
and panoramic x-ray (D0330) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Gel-one injection.
You asked the Plan to pay for a Gel-one injection. You say that this injection is medically necessary because other medications have not worked. You said that your knee is 'bone-on-bone' and you need to use a cane. You said that you are having balance issues and pain. The Plan denied your request. The Plan says you do not meet Medicare criteria for this injection.
The Plan follows Medicare rules. Medicare rules say that Gel-One can only be considered if there is evidence that you have tried and failed at least three months of conservative therapy. 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 a Gel-one injection. Our reviewer says that you do not meet criteria for this injection. Our physician reviewer found there is no record from the Physical therapist that therapy was completed or could not be tolerated. There is no documentation of trial and failure or contraindication of at least 3 months of conservative therapy as required. 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 Gel-one injection have not been met. Therefore, we decided that the Plan does not have to pay for a Gel-one injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content cap for bridge for 
teeth 11, 13, 18, and 20 (D6750) and false tooth for bridge for teeth 12 and 19 (D6240). 
 
You asked the Plan to pre-approve the requested dental services. You say that this dental care is necessary for 
your condition. The Plan denied your request. The Plan says the contractual coverage rules have not been 
satisfied for the requested dental care. 
 
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. The Plans benefit states that 
fixed bridges are usually considered beyond the scope of the program. To approve a bridge you must be 
missing only one upper front tooth or only two lower front teeth. The two lower front teeth must be next to 
each other. You also cannot be missing any of your back teeth. 
 
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 requested dental services. Our 
reviewer says that the requested dental services are not necessary according to the Plan's contractual coverage 
rules. Our physician reviewer found the Plan allows for replacement of a single upper anterior tooth or two 
adjacent lower anterior teeth. As there are numerous missing posterior teeth in both the lower and upper arches, 
the Plan criteria have not been met for the requested fixed bridges. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the requested dental services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve white glass with high gold content cap for bridge for teeth 11, 13, 18, and 20 
(D6750) and false tooth for bridge for teeth 12 and 19 (D6240).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the transport parking fees/tolls (A0170) and fixed wing air mileage 
(A0435) provided on May 21, 2020. 
 
You asked the Plan to pay for the transport parking fees/tolls and fixed wing air mileage. You say that there are 
medically necessary inter-facility fixed-wing air ambulance transportation services which has an outstanding 
balance that the Plan must cover. The Plan denied your request. The Plan says that the enrollee has no pre-
authorization on file for the receiving facility. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 transport parking fees/tolls and fixed 
wing air mileage. Our reviewer says that these services were medically reasonable and necessary for the 
enrollee. Our physician reviewer found the documentation does support that the patient suffers from an illness 
or injury that contraindicated transportation by any means other than ambulance. Our reviewer found that the 
documentation does support that the patient's condition was such that the time needed to transport the patient 
by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. The distance was too far, and ground transportation would have taken too long. 
Our physician reviewer also found that the documentation does support that the transferring hospital did not 
have adequate facilities to provide the medical services needed by the patient. 
 
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 transport parking fees/tolls and fixed wing air mileage have been met. 
Therefore, we decided that the Plan has to pay for the transport parking fees/tolls (A0170) and fixed wing air 
mileage (A0435) provided on May 21, 2020.  
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower overdenture (D5865). 
 
You asked the Plan to pre-approve a complete lower overdenture. You say that you would like the Plan to help 
pay the cost for the requested service. The Plan denied your request. The Plan says the service at issue 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 pre-approve a 
complete lower overdenture (D5865).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81321, 81206, 
81210, 81235, 81272, 81275, 81276, 81301, and 81311) provided on September 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for 
molecular pathology testing (CPT code(s): 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 
81311) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the accession of tissue, gross and microscopic examination, 
preparation and transmission of written report (D0473) and incisional biopsy of oral tissue (D7286) provided 
on July 29, 2021. 
 
  You asked the Plan to pay for the accession of tissue, gross and microscopic examination, preparation and 
transmission of written report and incisional biopsy of oral tissue. You say that you understand that the 
provider was out-of-network, but you were advised to submit a claim for reimbursement. You also say that you 
are on a fixed income and had to use a credit card to pay the provider. The Plan denied your request. The Plan 
says you received these services from a provider who had opted out of the Medicare program. 
 
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 
accession of tissue, gross and microscopic examination, preparation and transmission of written report (D0473) 
and incisional biopsy of oral tissue (D7286) provided on July 29, 2021.