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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that CPT 81455 is not covered. 
 
This test is unlikely to impact therapeutic decision-making in the clinical management of the patient. It is 
denied automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on September 28, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for religious treatment provided to the enrollee on July 11, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee has a condition that qualifies for Medicare 
coverage. The Plan denied your request. The Plan says the admission to this facility was purely custodial in 
nature. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
The services at issue in this case are not medical in nature. The provider is not a skilled nursing facility and 
does not provide medical services. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for religious treatment 
provided to the enrollee on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopic wedge liver biopsy provided on December 
29, 2021, billed with code 47100. 
 
You asked the Plan to pay for the biopsy as billed. You say that this was billed correctly and should be paid. 
The Plan denied your request. The Plan says the billed code is not correct to report a laparoscopic liver biopsy. 
 
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, the CPT Code Manual definition of code 47100 is Biopsy of liver, wedge. 
 
We find that CPT code 47100 is not supported in the medical record. Specifically, according to the CPT 
Assistant Bonus Edition (December 2014, Volume 24, Issue 12, pages 18-19), there is no specific CPT code to 
describe laparoscopic wedge liver biopsy. Code 47379, Unlisted laparoscopic procedure, liver, would be 
reported without any CPT modifier. Based on this information, we decided that Medicare rules for coverage of the biopsy as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
laparoscopic wedge liver biopsy provided on December 29, 2021, billed with code 47100.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by a non-Plan 
cardiologist. 
 
You asked the Plan to pre-approve physician's services to be provided by a non-Plan cardiologist. The Plan 
denied your request. The Plan says the Plan has specialists in-network that can provide the member with a 
treatment plan. The member will be offered a second opinion with a Health Plan Cardiologist. The member is 
contractually required to obtain this service from network providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by a non-Plan cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implant you received on February 7, 2022. 
 
You asked the Plan to pay for the dental implant. You say that you were originally told that your dental benefit 
would cover a crown at 50%. However, the tooth caused discomfort and is visible, so an implant was the only 
option. The Plan denied your request. The Plan says dental implants are not covered. 
 
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. The Plan only covers those dental services listed in your 
Comprehensive Dental Benefit chart. Dental implants are not listed as covered services, regardless of the 
reason or necessity for the implant. Therefore, we decided that the Plan does not have to pay for the dental 
implant you received on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation, with a finding 
of high risk (D0603) provided January 13, 2022, and the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and panoramic radiographic image 
(D0330) provided January 31, 2022. 
 
You asked the Plan to pay for the caries risk assessment, tooth extractions, and panoramic x-ray. You say that 
your x-rays were necessary for your extractions. The Plan denied your request. The Plan says the tooth 
extractions have processed correctly, you have exceeded the frequency limit for the panoramic x-rays and the 
caries risk assessment is not covered under your benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the panoramic 
x-ray once every 36 months and covers tooth extractions with 20% coinsurance.  
 
We looked at the file and Medicare rules. You have been asked to pay 20% of the allowed amount for the tooth 
extractions. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. Therefore, we decide that the Plan does not have to provide additional payment for the extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided January 31, 2022. The Plan provided documentation showing that a full series of intraoral x-rays was 
previously covered on January 13, 2022. 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 caries risk assessment is not among those covered services. Therefore, we decided that 
the Plan does not have to pay for the caries risk assessment and documentation, with a finding of high risk 
(D0603) provided January 13, 2022, and panoramic radiographic image (D0330) provided January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you need this service because you are in 
pain and are unable to eat. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation - per quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic images (D0330) provided by a participating 
provider on December 16, 2021. 
 
You asked the Plan to pay for panoramic images. 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 a not a covered dental 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 
panoramic images (D0330) provided by a participating provider on December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not require SNF level of care. 
 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 the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract removal for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is unable to enjoy daily activities 
due to the fear of driving with his current visual acuity. The Plan denied your request. The Plan says that 
clinical notes do not support that a cataract is causing a problem with your vision that cannot be corrected to 
satisfactory function without surgery. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The clinical 
documentation does not support that the enrollee has symptomatic impairment of visual function not 
correctable with a tolerable change in glasses or contact lenses resulting in specific activity limitations and/or 
participation restrictions. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cataract removal for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on October 12, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this is covered by Medicare. The Plan denied your 
request. The Plan says tests submitted under code 81455 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. The genetic testing at issue was billed with 81455 and is not 
considered medically necessary. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing 
(81455) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for an office visit. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers within a reasonable distance. 
 
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 
an out-of-network referral for an office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal manual manipulation and electrical 
stimulation provided on December 15, 2021. 
 
You asked the Plan to pay for the non-Medicare covered chiropractic care. You say that this should be covered 
due to medical necessity. The Plan denied your request. The Plan says the spinal manipulation has been paid. 
However, the enrollee received the 30 non-Medicare covered visits by the date of service at issue. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers coverage of additional chiropractic 
services but limits this coverage to 30 visits per year. 
 
The records show that the service at issue is not manual manipulation of the spine. The record also shows that 
the Plan has paid for 30 non-spinal manipulation visits in 2021 prior to the date at issue. Therefore, we decided 
that the Plan does not have to pay for the extraspinal manual manipulation and electrical stimulation provided 
on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 8 and 9. 
 
You asked the Plan to pre-approve the dental services. You say that you are dissatisfied because this service is 
not covered. The Plan denied your request. The Plan says core build up is not listed as covered. 
 
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 core build up procedures 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve core build up (D2950) for teeth # 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services provided on July 19, 2021, 
billed with codes 99100 and 99140. 
 You asked the Plan to pay for the services as billed. You say that payment should be made for this claim. The 
Plan denied your request. The Plan says the two remaining codes are denied correctly as they are not separately 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99140 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the special anesthesia services provided on July 19, 2021, billed with codes 99100 and 
99140.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interrogation device evaluation provided to the enrollee 
on December 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says remote interrogation services 93295 are 90-day services, and may only be reported once during 
that period regardless of the number of interrogations performed. 
 
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, the CPT Code Manual definition of code 93295 is "Interrogation device evaluation(s) (remote), up 
to 90 days; single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s) and 
report(s) by a physician or other qualified health care professional." 
 
We find that CPT code 93295 is not supported in the medical record. Specifically, this code was already billed 
less than 90 days before this date of service on September 23, 2021. It is not appropriate to bill this code less 
than 90 days apart.  
 Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for an interrogation device evaluation provided to the 
enrollee on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing related to end-stage renal disease 
(ESRD) provided on September 24, 2021. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that these labs are separately payable. The 
Plan denied your request. The Plan says payment for lab testing for ESRD patients is included in payment to 
the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 testing related to end-stage renal disease (ESRD) provided on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87653, 87481, 87500, 87789, 87640, 87651) 
provided on May 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not pre-authorized or medically necessary. 
 
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 requested 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 service 
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 lab services (87653, 87481, 87500, 87789, 87640, 87651) provided on 
May 4, 2021.