Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. 
 
You asked the Plan to pre-approve skilled nursing services. You say that the enrollee needs home health 
services. The Plan denied your request. The Plan says the service you are requesting does not meet the 
requirements for approval. 
 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 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 skilled nursing services. Our reviewer 
says that the requested home health skilled nursing services are not medically necessary or reasonable. Our 
physician reviewer found the enrollee does not have documented skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99214) provided on 
January 26, 2022, to February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the Plan is confused as to under 
which policy you fall. The Plan denied your request. The Plan says rules for payment for OON care have not 
been met. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (99214) provided 
on January 26, 2022, to February 23, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole. 
 
You asked the Plan to pre-approve Pantoprazole. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole.  
 
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (code D5120) and 
complete denture-mandibular (code D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the replacement of missing teeth is 
necessary for the enrollee to chew and digest food properly. 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 February 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - mandibular (code 
D5120) and complete denture-mandibular (code D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase reimbursement for core build up (D2950), crowns (D2740 x 
2), and an unspecified adjunctive procedure (D9999) provided on December 23, 2021. 
 
You asked the Plan to increase reimbursement for the dental services. You say that you should have been 
reimbursed another $855.50. The Plan denied your request. The Plan says you have been reimbursed the 
correct amount. 
 
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 paid $289 towards your dental services received on December 23, 2021. The Plan 
reimbursed you 50% of the amount you paid ($289 x 50% = $144.50).  Therefore, we decided that the Plan 
does not have to increase reimbursement for core build up (D2950), crowns (D2740 x 2), and an unspecified 
adjunctive procedure (D9999) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal pocket irrigation, per quadrant (code D4921). 
 
You asked the Plan to pre-approve pocket irrigation. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your dental benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal pocket irrigation using medicinal agents, per quadrant (code D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vacuum socket system. 
 
You asked the Plan to pre-approve the vacuum socket system. You say that this item is medically necessary. 
The Plan denied your request. The Plan says the requested item is considered experimental/investigational. 
 
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 the vacuum socket system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the literature reviewed indicates that further research is needed with clinical 
trials that recruit larger sample sizes and report long-term outcome data for the requested vacuum suspension 
system. 
 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 vacuum socket system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the vacuum socket system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on March 22, 2021. 
 
You asked the Plan to pay for the general health panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on March 22, 2021.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility.

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 pre-approve a comprehensive oral evaluation (D0150) and three (3) 
tooth extractions (D7210). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and tooth extractions. You say that you 
followed the rules of the plan by going to a general dentist, but the dentist advised it is beyond his expertise and 
only an oral surgeon can perform the extraction. The Plan denied your request. The Plan says dental services 
are covered when performed by a participating general dentist. Consults and dental services provided by Oral 
Surgeons, Periodontists, Endodontists, other dental specialists, or non-network General Dentists 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. The Plan covers a 
comprehensive oral evaluation and tooth extraction once per year. Services must be performed by a 
participating general dentist.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and tooth extractions. have not been met. Specifically, dental 
services must be performed by a participating general dentist. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and three (3) tooth extractions (D7210).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart (75571). 
 
You asked the Plan to pre-approve a CT of the heart. The Plan denied your request. The Plan says this study is 
not covered for screening purposes. The Plan also says that it was confirmed with the provider's office that this 
test is ordered for screening purposes pertaining to Hyperlipidemia. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a CT of the heart, is being requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) of the heart (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for residential treatment provided on November 1, 2021, to 
December 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for residential treatment. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available who could have provided 
these services. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for residential treatment provided on November 1, 
2021, to December 1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit/oncology service to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve [Shorter description of ITEM or SERVICE at issue, e.g. "a power 
wheelchair"]. You say that the services should be covered as you disagree with the denial and would like to 
continue seeing your provider. The Plan denied your request. The Plan says the services denied correctly as 
they are non-emergent and care can be provided in-network. 
 
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 office visit/oncology service to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2021. 
 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 the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62323). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the 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 repeat epidural steroid injections are covered when 
the first injection directly and significantly provided improvement of the condition being treated and when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the records do not 
show that the previous injections provided at least 50% pain relief for 3 months. 
 
 
 
 
 
 
 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 21, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
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 
October 21, 2021 billed with codes 81206 and 81292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2021, billed with 
codes 81206, 81235, 81292, 81301 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 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 
October 25, 2021, billed with codes 81206, 81235, 81292, 81301 and 81321.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intra-dialytic parenteral nutrition (IDPN) (B4224, 
B4197, B4220). 
 
You asked the Plan to pre-approve IDPN. You say that the requested nutrition is medically necessary. The Plan 
denied your request. The Plan says the requested nutrition does not meet criteria. 
 
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 IDPN. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a listed diagnosis of unspecified severe protein-calorie malnutrition. 
Intraperitoneal nutrition therapy has been administered, and the enrollee's albumin level has improved from 2.8 
g/dL to 3.9 g/dL. It is stated by the IDPN provider that the enrollee is at high risk for recurrent hospitalizations. 
There is insufficient documentation to support that IDPN is medically reasonable and necessary for the enrollee 
in this case and will impact outcomes for her. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intra-dialytic parenteral nutrition (IDPN) (B4224, B4197, B4220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for primary care telehealth visits provided on 
January 21, 2022, and March 9, 2022. 
 
You asked the Plan to waive the copayments for the telehealth visits. You say that you did not request the 
phone calls and should not have to pay for them. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each PCP telemedicine visit.  
 
You have been asked to pay a $10 copayment for each of the telehealth visits, for a total of $20. The telehealth 
visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for primary care telehealth visits provided on January 21, 
2022, and March 9, 2022.