Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does 
not require 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. You appear 
to still be unstable and require additional acute care services that can safely be administered at the current 
facility until more stable for transfer. You do not require services at the LTACH that are not already available 
at the current facility. Our physician reviewer found that your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2), 
three localized deliveries of antimicrobial agents (D4381 x3), two gingival irrigations (D4921 x2), and drugs or 
medicaments dispensed in the office for home use (D9630) provided on January 5, 2022. 
 
You asked the Plan to pay for the scalings and planings, localized deliveries of antimicrobial agents, gingival 
irrigations, and drugs or medicaments. You say that you went for a cleaning and told them what your insurance 
covers. The Plan denied your request. The Plan says these services are not covered expenses under your dental 
plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 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 pay for the two 
periodontal scalings and root planings (D4341 x2), three localized deliveries of antimicrobial agents (D4381 
x3), two gingival irrigations (D4921 x2), and drugs or medicaments dispensed in the office for home use 
(D9630) provided on January 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 24, 2021, through 
April 12, 2021. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the provider 
did not submit the RAP claim until February 25, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
  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 RAP was not submitted within 5 
calendar days. Therefore, we decided that the Plan does not have to pay for home health services provided from 
March 24, 2021, through April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on March 6, 2022. 
 
You asked the Plan to pay for genetic panel testing. You say that this testing has been determined by Medicare 
to be reasonable and necessary for management of the enrollee's advanced cancer. The Plan denied your 
request. The Plan says this test panel included the FANCC gene and is therefore not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels including the FANCC gene 
will be denied.  
 
We looked at the file and Medicare rules. This test panel included the FANCC gene and is therefore 
automatically denied by Medicare. Based on this information, we decided that Medicare rules for coverage of 
genetic panel testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic 
panel testing provided on March 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 3, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99152) provided on October 15, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99152 is 
not supported by the records provided. Our reviewer found that the billed date of service is incorrect as the documentation describes admission from emergency department prior to fracture treatment and sedation. 
Additionally, the documentation for moderate sedation does not include documentation of an independent 
trained observer to assist in the monitoring of patient's level of consciousness and physiological status, 
therefore criteria for this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 the anesthesia services (99152) provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), the first 
periapical x-ray (D0220), each additional periapical x-ray (D0230 x7), the bitewing x-ray (D0274), and the 
cleaning (D1110) provided by an out-of-network provider on April 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the dental office 
accepted your insurance. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the first periapical x-ray (D0220), the 
bitewing x-ray (D0274), and the cleaning (D1110) provided by an out-of-network provider on April 29, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation (D0150) was exhausted on date of service June 29, 
2021. The record also shows your benefit for the first periapical x-ray (D0220) was exhausted on date of 
service April 29, 2022. Therefore, we decided the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and each additional periapical x-ray (D0230 x7). 
  
Your complaint that the dentist took unnecessary x-rays is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a mandibular partial denture (D5761) provided 
on May 3, 2022. 
 
You asked the Plan to pay for the reline of a mandibular partial denture. You say that this service needed to be 
done because your partial denture was so loose you could not eat. The Plan denied your request. The Plan says 
this service is not covered under your 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 pay for the reline 
of a mandibular partial denture (D5761) provided on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2022. 
 
You asked the Plan to pay for lab tests. You say that the public health emergency allows claims to be filed past 
the timely filing limit. The Plan denied your request. The Plan says there was not enough information 
submitted to justify payment of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The records submitted do not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules 
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the enrollee has some Parkinson's features, and 
a host of other health issues as well. You also say that you would rather not expose the enrollee to Parkinson 
medications without more confidence that they actually have Parkinson's disease. The Plan denied your 
request. The Plan says the requested imaging is not medically reasonable and appropriate. 
 
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 a SPECT scan. Our reviewer says that 
the requested SPECT scan is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provider noted that the enrollee did not readily have a presentation consistent with 
Parkinson's Disease (PD). A DaTscan is generally reserved to differentiate between essential tremor and PD in 
overlapping presentations. Our reviewer found that such a situation was not present in this case. Our physician 
reviewer also found that given the lack of signs to readily suggest the presence of PD, performance of a 
DaTscan cannot be said to reflect the most appropriate supply that can be provided to the enrollee at this time. 
 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on March 2, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial of the submitted claim. 
You have provided medical records to show medical necessity. The Plan denied your request. The Plan says the 
unique test identifier requirement is missing. 
 
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 code 0037U is not supported in the medical record. Specifically, the LCD shows that 
providers receive an identifier specific to the test and submit the test assigned identifier with the claim for 
reimbursement. A test identifier was not submitted; therefore, the claim remains denied. 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 (0037U) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair accessory, one-arm drive attachment 
(E0958) provided on April 8, 2022. 
 
You asked the Plan to pay for a manual wheelchair accessory. You say that you disagree with the denial of this 
charge. The Plan denied your request. The Plan says you did not bill as required by Medicare coding 
regulations. 
 
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 code E0958 is not supported in the medical record. Specifically, code E0958 was not billed 
with the required modifier. Based on this information, we decided that Medicare rules for coverage of a manual 
wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to pay for a manual 
wheelchair accessory, one-arm drive attachment (E0958) provided on April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with limited field of view (D0380) provided on April 7, 2022. 
 
You asked the Plan to pay for the cone beam CT image capture with limited field of view. You say that you 
were in pain and were unable to locate an in-network provider who had an emergency appointment available. 
The Plan denied your request. The Plan says this service 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 pay for the cone 
beam computed tomography (CT) image capture with limited field of view (D0380) provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for physician's services provided in Egypt from 
January 23, 2022, to March 6, 2022. 
 
You asked the Plan to reimburse you for physician's services. You say that you are unable to provide proof of 
payment because you paid cash for all of the services you received as the provider did not accept debit/card 
payments. The Plan denied your request. The Plan says there is insufficient documentation and no proof of 
payment received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physician's services provided in Egypt 
from January 23, 2022, to March 6, 2022 have been met. You have not provided the necessary medical records and proof of payment.  Therefore, we decided that the Plan does not have to reimburse you for physician's 
services provided in Egypt from January 23, 2022, to March 6, 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. You say that you are requesting inpatient rehabilitation services. 
The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Intraoral- periapical first radiographic image provided on 
May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the radiographic image was necessary to 
determine the issue. The Plan denied your request. The Plan says your benefit for the requested 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 May 2, 2022. Therefore, 
we decided that the Plan does not have to pay for Intraoral- periapical first radiographic image (code D0220) 
provided on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with codes 81286, 81400, 81413, 
81414, 81442 and 81479 for date of service December 1, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the treatment in dispute was medically 
necessary to treat the enrollee based on the enrollee's medical condition. You say that the records provided 
substantiate the place of service billed. The Plan denied your request. The Plan says the testing in dispute does 
not meet Medicare coverage criteria.  
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. Medicare rules also say that tests not ordered by the physician who is treating the beneficiary are not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The progress note from the date of the order does not show that the 
need for this testing was discussed or that there was any documented intent to provide this testing. As such, we 
cannot confirm that the test was ordered by a physician treating the enrollee for a specific medical problem, or 
that the results would be used in the management of a specific medical problem. Based on this information, we 
decided that there is insufficient information in the record to determine if Medicare rules for coverage of 
laboratory services billed with codes 81286, 81400, 81413, 81414, 81442 and 81479 for date of service 
December 1, 2020. have been met. . Therefore, we decided that the Plan does not have to pay for laboratory 
services billed with codes 81286, 81400, 81413, 81414, 81442 and 81479 for date of service December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
(E2311), expandable controller harness (E2313) and a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that there is not a medical need to control these power options through the 
joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 
 
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 items. Our reviewer says that an 
expandable controller, electronic connection and an expandable controller harness are not considered medically 
reasonable and necessary in this case. The enrollee does not require these items as he has more than adequate 
upper body function to handle individual switches. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of an expandable controller, electronic connection and an expandable 
controller harness. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377), electronic connection (E2311), expandable controller 
harness (E2313) and a power seat elevation feature (E2300) for the enrollee.