Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 3 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
was for a medical exam. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on October 3 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted procedure, vascular surgery (37799). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our physician reviewer 
found the documentation does not meet coverage criteria. Review of the entire coverage policy confirms that 
the Health Plan does not provide for primary stab phlebectomy. Phlebectomy is only covered in an adjunctive 
setting in which saphenous reflux is concurrently being treated or has been previously treated and the tributary 
in question measures 3mm in diameter or greater. In this case, there is no evidence previous saphenous reflux 
treatment and the size of the vein to be treated is not provided. Coverage criteria not met. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the unlisted procedure, vascular surgery (37799).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite fillings on tooth #9, 10, and 11 
(D2335), custom fabricated abutments on tooth #4, 5, and 13 (D6057), abutment supported crowns on tooth #4 
and 5 (D6058), a porcelain pontic on tooth #6 (D6240), a resin pontic on tooth #7 (D6250), retainer crowns on 
tooth #5, 8, and 13 (D6740, D6750), and extractions of tooth #23, 24, 25, and 26 (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve resin-based 
composite fillings on tooth #9, 10, and 11 (D2335), custom fabricated abutments on tooth #4, 5, and 13 
(D6057), abutment supported crowns on tooth #4 and 5 (D6058), a porcelain pontic on tooth #6 (D6240), a 
resin pontic on tooth #7 (D6250), retainer crowns on tooth #5, 8, and 13 (D6740, D6750), and extractions of 
tooth #23, 24, 25, and 26 (D7140).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that it is felt that the records support that 
payment should be made. The Plan denied your request. The Plan says payment for code 76882 is bundled into 
payment for code 93926. 
 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 76882 
is a column II code to column I code 93926. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76882 billed for date of service July 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 Injections. 
 
You asked the Plan to pre-approve the injections. You say that this injection is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate. 
This documentation includes, but is not limited to, relevant medical history, physical examination and results of 
pertinent diagnostic tests or procedures, and history of pharmacologic 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 pre-approve the injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found provided records document 
prior injections of the left knee with Gelsyn-3 provided no relief of the patient's knee pain. Provided records do 
not document any imaging studies or signs or symptoms related to the right knee confirming the diagnosis of 
osteoarthritis. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn-3 Injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and retreatment of previous root canal therapy (D3348) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to this provider because they were 
highly recommended. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Additionally, the requested items or services are 
not listed as covered under any circumstance. Therefore, we decided that the Plan does not have to pay for the 
core buildup, including any pins when required (D2950) and retreatment of previous root canal therapy 
(D3348) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210) and a consultation (D9310) for tooth 
#2, #17, #20, #25, and #31 provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the extractions (D7210) and a consultation (D9310) for tooth #2, #17, #20, #25, and #31 provided on 
May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery because of complications which do not require 
additional trips to the operating room are included in the global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 63663 was related to and billed within 10 days of 
minor surgical procedure 63650 performed on June 21, 2022. Payment for code 63663 is included in the global 
surgical payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered 
on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
December 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you should not owe this. 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 requested item or service was exhausted on date of service December 8, 2020. 
Therefore, we decided that the Plan does not have to pay for the remaining balance for dental services provided 
by a participating provider on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve a lumbar-spine MRI scan. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 lumbar-spine MRI scan. Our reviewer 
says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has worsening left-leg radicular symptoms and new onset of weakness that was not present 
during an encounter in 2021. The enrollee has multilevel degenerative changes on X-ray. The enrollee has 
completed a full course of physical therapy, beginning in April 2022, without relief. 
 
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 lumbar-spine MRI scan have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI scan of the lumbar spine (72148).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services needed could be provided in another setting, 
such as an acute rehabilitation facility, skilled nursing facility, outpatient setting or home care. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you believe you have extenuating 
circumstances and request to be granted additional rides. The Plan denied your request. The Plan says you have 
exhausted all 50 of your trips according to your plan benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you have neuropathy and gout and are in 
need of more assistance with physical therapy exercises and assistance to gain more strength. The Plan denied 
your request. The Plan says your request is not medically necessary because your records do not show that you 
are under the care of a physician or other allowed practitioner who has developed and certified a plan of care. 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 looked at the file and Medicare rules. The Medicare Benefit Policy Manual confirms that you must meet 
coverage criteria to home health services. The records do not show that you are receiving services under a plan 
of care established and reviewed by a physician. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-
approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 
minutes (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic material (D4265) and gingival irrigation 
(D4921) for tooth #2. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get the 
procedures done. The Plan denied your request. The Plan says denial of authorization for these services is 
correct, because biologic material and gingival irrigation are not covered by the 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 
biologic material (D4265) and gingival irrigation (D4921) for tooth #2.
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 enrollee requires close daily oversight of care by 
a physician in an inpatient setting. You say that the enrollee has actively participated with all therapeutic 
modalities and demonstrated their ability to tolerate an acute rehab program to regain their previous functional 
status. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee can get the services they need provided safely in other settings. 
 
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 that the enrollee does not have complex or intensive medical rehabilitation needs. 
The enrollee is chronically deconditioned and is at a min assist level without any rehabilitation needs beyond 
regaining strength and addressing their underlying chronic deconditioned state. The enrollee's chronic medical 
conditions are stable and routinely addressed at an outpatient level. The IRF is not a medical step-down unit 
absent intensive rehabilitation needs.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 14, 2022, to 
April 12, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that HHA should submit artificial admission date on 
all subsequent claims until the beneficiary is discharged and another NOA is required.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the admission date reported on the claim for 
the services at issue does not match the admission date on the NOA. Therefore, we decided that the Plan does 
not have to pay for home health services provided from March 14, 2022, to April 12, 2022.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollees condition they do not meet all the requirements. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the medical records support a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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.