Persius/hicric huggingface dataset:
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 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 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or documented skilled 
therapy needs. The enrollee appears to have reached a new plateau in function. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 19, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this stay was medically necessary. The 
Plan denied your request. The Plan says based on the provided records, inpatient criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee's symptoms resolved and there were no persistent neurological 
deficits on examination. Based on how quickly the enrollee's symptoms resolved with clinical and 
hemodynamic stability, it was not expected that the enrollee would require hospital treatment that would likely 
cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided March 19, 2022, to March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve the nerve block. You say that you feel this is medically necessary. You also 
say that your doctor deems it medically necessary. The Plan denied your request. The Plan says radiofrequency 
ablation is being pursued for pain control from bone disease and not peripheral nerve disease. The Plan also 
says you are not a candidate for knee replacement. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral nerve blocks will be considered medically 
reasonable and necessary for normally temporary conditions. 
 
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 nerve block. Our reviewer says that 
the requested nerve block is not medically necessary. Our physician reviewer found the provided 
documentation indicates the service in this case is being requested for knee pain caused by osteoarthritis. 
Medicare does not cover this procedure for bone disease. Therefore, the coverage criteria have not been met 
according to the documentation provided. 
 
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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left genicular nerve radiofrequency ablation (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator placement (64555). 
 
You asked the Plan to pre-approve the nerve stimulator placement. You say that this service 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 nerve stimulator treatment is covered when 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 nerve stimulator placement. Our 
reviewer says that the requested nerve stimulator treatment is not medically necessary. Our physician reviewer 
found the requested treatment is not supported for the treatment of non-specific neuropathy of the lower 
extremities. 
 
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 nerve stimulator placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a nerve stimulator placement (64555).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the head or brain CT scan (CPT code 70450) provided on 
April 22, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 the head or brain CT scan (CPT code 70450) provided on April 
22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) provided March 1, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that based on Local Coverage Article: Billing and Coding: MolDX: 
FANCC Genetic Testing (A53628), Gene panels that include the FANCC gene are non-covered. 
 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers Next Generation Sequencing 
(NGS) as a diagnostic laboratory test when certain criteria are met. 
 
We looked at the file and Medicare rules. This service is covered for the enrollee's condition nationally based 
on the National Coverage Determination. A local coverage article cannot restrict coverage of a panel that is 
nationally covered. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have been met. Therefore, we decided that the Plan has to pay for genetic testing (0037U) provided 
March 1, 2022.  
 
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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for sacral wounds and renal failure. The 
enrollee is receiving antibiotics and has been started on hemodialysis. The enrollee is not intubated/ventilated. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from January 19, 2022, through 
January 31, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee was enrolled in hospice at the time of services. The Plan states per Medicare 
guidelines, the enrollee's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services provided from January 19, 2022, through January 
31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), 
problem focused limited oral evaluation (D0140), and surgical extraction (D7210) provided on April 20, 2022, 
and May 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the bone replacement graft, problem focused limited oral evaluation, and surgical 
extraction. You say that you were told that your policy should cover extractions in full. You also say that you 
feel the Plan should pay for the extraction, and you should not be punished for needing a blood thinner. The 
Plan denied your request. The Plan says the bone replacement graft is not a covered expense under your dental 
plan. The Plan also says that these services were performed by an OON provider, and you are responsible for 
any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. 
 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, bone replacement graft for ridge 
preservation (D7953) is not among those covered under this benefit. You are also responsible for the difference 
between the billed amounts and allowed amounts for covered dental services rendered by an OON provider. 
Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation 
(D7953), problem focused limited oral evaluation (D0140), and surgical extraction (D7210) provided on April 
20, 2022, and May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921 x 2) provided on 
May 5, 2022. 
 
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 these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigationper quadrant (D4921 x 2) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for intraoral - periapical each additional 
radiographic image (D0230), intraoral - periapical first radiographic image (D0220), comprehensive 
periodontal evaluation (D0180), and the Plan does not have to pay for the cone beam CT image capture 
(D0383) provided on  May 23, 2022. 
 
You asked the Plan to waive the cost share for the radiographic images and evaluation and to pay for the cone 
beam CT. You say that you feel like insurance paid the minimum on the claim and you cannot afford these 
charges. The Plan denied your request. The Plan says the cost share applied correctly and the cone beam CT is 
not a covered benefit under your dental plan. 
 
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 will be reimbursed 
at 100% for In-Network Medicare PPO Providers and 50% for Out-of-Network Non-Medicare Providers.  
 
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 have been asked to pay $316.50 for the dental services. The dental services fall within the Dental Services 
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. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested cone beam CT image capture 
(D0383) is not among those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to waive the cost share for intraoral - periapical each 
additional radiographic image (D0230), intraoral - periapical first radiographic image (D0220), comprehensive 
periodontal evaluation (D0180), and the Plan does not have to pay for the cone beam CT image capture 
(D0383) provided on  May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care starting September 8, 
2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says based on the emergency room and admission 
records on September 8, 2022, medical needs could have been met at an observation level of hospital care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee responded to initial early treatment with stable vitals and 
symptoms. Based on the provided documentation observation status was more appropriate until appropriate for 
a lower level of care and inpatient care was not needed. There was no suggestion that the enrollee would 
require hospital care that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care starting September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture-flexible base (including 
retentive/clasping materials, rests, and teeth) (D5225) provided on April 13, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy. 
 
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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the upper partial 
denture-flexible base (including retentive/clasping materials, rests, and teeth) (D5225) provided on April 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the bitewing x-rays-four 
radiographic images (D0274) provided on June 3, 2022. 
 
You asked the Plan to pay for the dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 
dental cleaning (D1110) and the bitewing x-rays-four radiographic images (D0274) provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6, 2022 billed with 
codes 81455, 81301 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 6, 2022 billed with codes 81455, 81301 and 81194.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The patient 
appears to be still unstable (encephalopathy) and requires additional acute care services including additional 
weaning that can safely be administered at the current facility until more stable for transfer. The patient does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.