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

 
We decided that the Plan does not have to pay for the inherited cardiomyopathy gene panel provided on July 
28, 2021. 
 
You asked the Plan to pay for the gene panel. The Plan denied your request. The Plan says the testing does not 
meet coverage criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The case file shows that the provider canceled the genetic testing. The 
records do not show that the testing was ordered for a specific medical problem. Medicare does not cover this 
test for screening purposes. Therefore, we decided that the Plan does not have to pay for the inherited 
cardiomyopathy gene panel provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positive emission tomography (PET) services. 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary. 
You say that you have lost over 50 pounds. The Plan denied your request. The Plan says a PET scan is not 
covered as a screening test for patients without specific signs or symptoms of disease. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record does not indicate that the 
enrollee has biopsy proven cancer or is strongly suspected to have cancer based on other diagnostic 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positive emission tomography (PET) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) and the 
psychotherapy services (90837 x 4) rendered by the out-of-network (OON) provider from June 7, 2021, 
through August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an ineligible, 
out of network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The rules also say that no provider or supplier shall receive 
payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the 
Medicare program. Additionally, Marriage family therapists are not eligible to enroll in Medicare. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
Additionally, this provider is not eligible to enroll in Medicare as he is a Licensed Marriage and Family 
Therapist. Medicare rules state that no provider or supplier shall receive payment for services furnished to a 
Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) and the 
psychotherapy services (90837 x 4) rendered by the out-of-network (OON) provider from June 7, 2021, 
through August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft. You say that you would like approval to provide 
these services. The Plan denied your request. The Plan says D7953 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 
bone replacement graft (D7953) to be provided by a participating provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the head. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee's symptoms of dizziness have resolved and there is no medical 
documentation indicating the computed tomography (CT) of the head is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found a patient on Coumadin 
who has a mechanical fall with headache and dizziness has a valid indication for CT of the brain without 
contrast to exclude an extra-axial hemorrhage. This exam should be approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the head.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services (45380, 45385, 45378) provided on 
June 2, 2021. 
 
You asked the Plan to pay for the colonoscopy services. You say that additional payment is due for these 
services, and they are not bundled procedures. The Plan denied your request. The Plan says proper payment for 
these services has been made according to Medicare rules. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code. The record clearly indicates that the Plan paid the full value 
of the highest valued endoscopy, plus the difference between the next highest and base endoscopy.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay an additional amount for the colonoscopy services 
(45380, 45385, 45378) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam (92015) provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $35 
copayment for Vision care.  
 
 
  You have been asked to pay a $35 copayment for the eye exam. Eye exams fall within the Vision care 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 an eye exam (92015) provided on November 8, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the elbow (73630) and the x-ray exam of 
the wrist (73110) rendered by the out-of-network (OON) provider on August 17, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the x-ray exam of the elbow (73630) and the x-ray exam of the wrist (73110) 
rendered by the out-of-network (OON) provider on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the lungs for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records provided do not show that the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has 
hypercalcemia following parathyroidectomy. It is not clear whether there is concern of parathyroid residual 
tumor or whether this  is a request for low dose computed tomography (LDCT) due to smoking history. In case 
of if there is a concern of parathyroid tumor a sestamibi nuclear medicine scan would be the first procedure of 
choice. If this exam is a lung cancer screening tool the patient's smoking history is not explained and the 
criteria for LDCT under that diagnosis are not met. Absent any further explanation of the rationale for the 
request CT of the chest the medical necessity of same has not been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the lungs for the enrollee.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that medical necessity 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 medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee does have documented skilled nursing needs. The enrollee appears to be receiving 100% of nutrition 
via a new feeding tube. The enrollee does not have documented skilled therapy needs. The enrollee appears to 
be at a new, lower, level of function. Daily skilled services are required to establish a maintenance program or 
to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve genicular nerve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve genicular nerve RFA services. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says genicular nerve destruction of nerve of the 
knee is not a standard treatment for knee pain. The Plan says that there is not enough medical proof that shows 
the safety and/or success of genicular nerve destruction of nerve of the knee when used for this reason. 
 
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 genicular nerve RFA services. Our 
reviewer says that genicular nerve RFA services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has right knee pain due to tri-compartmental osteoarthritis. She 
is using Tylenol, Tramadol, and diclofenac. She has not tried physical therapy for her knee pain. A knee brace 
was tried but made the enrollee's pain worse. The enrollee's right knee pain was rated 8/10. The provider has 
requested a genicular nerve radiofrequency ablation. Genicular nerve blocks and genicular nerve 
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve RFA services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a white glass with metal crown (D2751) for tooth #27. 
 
You asked the Plan to pre-approve a crown. You say that a post and core and root canal retreatment have been 
approved for this tooth. While the crown itself may not need to be replaced, the enrollee cannot walk around 
with just a post and core. The Plan denied your request. The Plan says that you already have a cap on this tooth. 
The x-rays of this tooth do not show that you have a cavity under the old cap. It is not medically necessary to 
provide a replacement at this time. 
 
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 a crown when 
the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
requested crown in this case is medically necessary and reasonable. Our physician reviewer found the 
documentation indicates that a root canal and post and core have been approved for tooth #27. It appears that a 
new crown would be reasonable and necessary since access through the old crown would be required to do the 
root canal. Since a post and core have been approved, a new crown would be fitted to this as well. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a white glass with metal crown (D2751) for tooth #27.  
 
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 palliative (emergency) treatment of dental pain 
(D9110), drugs dispensed for home use (D9630) an unspecified endodontic procedure (D3999) and an 
unspecified preventive procedure (D1999) on tooth #4 and tooth #12. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee is waiting for approval of these 
services. The Plan denied your request. The Plan says the requested services are not listed as covered benefits 
under the enrollee's plan. 
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 pre-approve 
palliative (emergency) treatment of dental pain (D9110), drugs dispensed for home use (D9630) an unspecified 
endodontic procedure (D3999) and an unspecified preventive procedure (D1999) on tooth #4 and tooth #12.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have documented skilled 
nursing needs nor documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs are custodial. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of all teeth and on cast framework 
(mandibular, D5671) to be provided by a participating provider. 
 
You asked the Plan to pay for the replacement of all teeth and on cast framework. You say that you would like 
the Plan to approve these dental services. The Plan denied your request. The Plan says D5671 is not a covered 
benefit. The Plan says that the enrollee does not carry the dental platinum rider. 
 
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 
replacement of all teeth and on cast framework (mandibular, D5671) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on 
September 17, 2021. 
 
You asked the Plan to pay for codes 81404 and 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81404 and 81479) provided on September 17, 2021.