Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81292, 81301) 
provided on September 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 81206, 81292, 81301) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (62320) provided November 22, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided to support the billed services. 
 
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 injections (62320) provided November 
22, 2021. have been met. Specifically, only records of the procedure were provided. The plan requested additional clinical records to support medical necessity. No additional clinical records were provided. 
Therefore, we decided that the Plan does not have to pay for injections (62320) provided November 22, 2021.
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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), unspecified preventive procedure, by report (D1999), deep 
sedation/general anesthesia - each subsequent 15-minute increment (D9223) and deep sedation/general 
anesthesia - first 15 minutes (D9222). 
You asked the Plan to pre-approve therapeutic parenteral drugs, unspecified preventative procedure, and deep 
sedation/general anesthesia. You say that the enrollee has anxiety. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for anesthesia. The therapeutic parenteral drugs and unspecified preventative 
procedure are not covered under the enrollee's benefits. 
 
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. The Plan covers deep 
sedation/general anesthesia when you meet criteria for coverage as explained in the Medicare Rules section of 
this letter.  
 
We looked at the file and Medicare rules. The documentation shows that the anesthesia is being requested with 
the extraction of one tooth. The Plan contacted the provider who stated that the enrollee has anxiety problems. 
The enrollee has not tried and failed nitrous oxide. There are no medical records provided to indicate that the 
enrollee has any qualifying conditions for coverage of the anesthesia. Based on this information, we decided 
that the Plan's rules for coverage of deep sedation/general anesthesia have not been met. Though the Plan offers 
dental benefits in excess of Medicare coverage, the therapeutic parenteral drugs and unspecified preventative 
procedure are not among those covered services. Therefore, we decided that the Plan does not have to pre-
approve therapeutic parenteral drugs, two or more administrations, different medications (D9612), unspecified 
preventive procedure, by report (D1999), deep sedation/general anesthesia - each subsequent 15-minute 
increment (D9223) and deep sedation/general anesthesia - first 15 minutes (D9222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dental extractions (D7140) provided 
on March 8, 2021, and June 14, 2021. 
 
You asked the Plan to waive the coinsurance for the dental extractions (D7140). You say that you would like 
the Plan to reconsider your request. The Plan denied your request. The Plan says you received a dental 
extraction with code D7140 on March 8, 2021, and June 14, 2021. The Plan says that the correct coinsurance 
has applied per your contract with the 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. 
We looked at the file and the Plan's contract. The Plan covers simple dental extractions with dental code 
D7140. The contract clearly says that enrollees must pay a 50% coinsurance for these dental extractions. The 
file shows you received a dental extraction with code D7140 on March 8, 2021, and June 14, 2021. The correct 
coinsurance has applied with a total of $90 ($45 for each extraction). Therefore, we decided that the Plan does 
not have to waive the coinsurance for the dental extractions (D7140) provided on March 8, 2021, and June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 22, 2021. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the decision to deny 
payment. The Plan denied your request. The Plan says this provider has not submitted clinical records to 
support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the provided records is not dated or signed by the doctor. Therefore, we decided that the Plan does not have to pay for injection, of 
diagnostic or therapeutic substances (anesthetic, antispasmodic, opioid, steroid, other solution), not including 
neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical 
or thoracic (62320) provided November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided February 1, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you required an evaluation 
for your dentist to create a treatment plan. 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 pay for the 
comprehensive periodontal evaluation - new or established patient (D0180) provided February 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from April 2, 2022, through 
April 27, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria.  
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 you did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, 
your functional improvement had plateaued by April 2, 2022, and you did not require any further inpatient 
skilled rehabilitation services. Your function was at or near your prior level of function and you could be 
discharged to a lower level of care for further services. As of April 2, 2022, you required custodial services. 
The denial for further inpatient skilled care is upheld. 
 
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 continuation of SNF care from April 2, 2022, through April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on November 22, 
2021. 
 
You asked the Plan to pay for the provided equipment. The Plan denied your request. The Plan says the 
provider is not listed as an acceptable provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The requested provider in this case is not a network provider with the Plan and not eligible to provide services 
under Original Medicare. The Plan had network providers available who could have provided the items 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 services. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided December 30, 2021. 
 
You asked the Plan to pay for the problem focused exam. You say that you wanted a second opinion before 
getting an uncovered procedure. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for this service. 
 
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. The Plan covers the problem 
focused exam once every 12 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a problem focused 
exam was previously covered November 8, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation - problem focused (D0140) provided December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on July 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that if they are a provider, 
do not know why you have to pay because they will not accept you if you do not pay. You also say that you do 
not want to change dentists. The Plan denied your request. The Plan says no prior authorization is on file and 
the treating provider is OON. The Plan also says that services need to be provided in-network to be eligible for 
payment. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120) and prophylaxis (D1110) provided on July 22, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation seven days a week to get your medication. The Plan denied your request. The Plan says that you have exhausted this benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty-six (36) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to provide coverage for the resin-based composite - one surface, posterior 
(D2391) provided October 25, 2021. 
 
You asked the Plan to provide coverage for the filling. You say that this service was necessary. The Plan 
denied your request. The Plan says that restorations are not allowable on a tooth with an existing crown. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plans coverage documentation provided does not appear to exclude fillings 
on teeth which have an existing crown. The Plan has not provided any medical records to review the medical 
necessity of this service. Therefore, we decided that the Plan has to provide coverage for the resin-based 
composite - one surface, posterior (D2391) provided October 25, 2021, according to your 2021 dental benefits.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (CPT code J7323). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you have not tried and failed the preferred step therapy (multi-injection) device(s): 
Orthovisc OR Supartz FX. The Plan states there is no indication the Plan's preferred agent(s) would likely be: 
less effective, and/or cause adverse effects. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Orthovisc or Supartz FX. The 
documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would 
likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa (CPT code J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 an epidural injection provided on 
November 22, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on December 27, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need to have dental x-rays performed in 
order to go through with heart surgery. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 and x-rays are covered once every 3 
years, the frequency limit has been exceeded. The record shows that the Plan paid for x-rays that you received 
on June 21, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray 
(D0210) provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt seating system (E1002) and wheelchair 
transit system (K0108). 
 
You asked the Plan to pre-approve a power tilt seating system and wheelchair transit system. You say that these 
wheelchair accessories are medically necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seating system - tilt only, recline only, 
or combination tilt and recline - will be covered when the beneficiary meets all the coverage criteria for a 
power wheelchair. Rules say that Medicare will pay for durable medical equipment that is needed for use in the 
home. 
 
We looked at the file and Medicare rules. In this case, the transit system is being requested specifically for use 
outside of the home. In addition, the enrollee does not meet the coverage criteria for a power wheelchair and 
has been approved for a manual wheelchair. The power tilt seating system will not be covered. Based on this 
information, we decided that Medicare rules for coverage of a power tilt seating system and wheelchair transit 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power tilt 
seating system (E1002) and wheelchair transit system (K0108).