Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Opdualag. Our reviewer says that the 
services are medically necessary. Our physician reviewer found in preliminary results of a phase I/II trial 
conducted in 43 patients with metastatic melanoma who had progressed on programmed cell death receptor 1 
(PD-1) or programmed death ligand 1 (PD-L1) inhibitors (including 70 percent [30 patients] with prior 
ipilimumab therapy), subsequent treatment with nivolumab plus relatlimab demonstrated objective response 
and disease control rates of 16 and 45 percent, respectively, and was well tolerated. Opdualag is FDA approve 
for use in metastatic melanoma. The service is reasonable and medically necessary and safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag have been met. Therefore, we decided that the Plan has to pre-
approve Opdualag.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation of wheezing represented by code 94060, 
diffusing capacity represented by code 94729, and plethysmography services represented by code 94726 billed 
for date of service October 7, 2021. 
 
You asked the Plan to pay for codes 94060, 94729, and 94726. You say that the claim in dispute was coded 
correctly. The Plan denied your request. The Plan says the services in dispute are not payable because they 
were billed with a place of service of an inpatient hospital with no modifiers appended. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report service correctly.  
 
We looked at the file and Medicare rules. The codes in dispute have a Physician Fee Schedule PC/TC indicator 
of 1 and the claim was billed with a POS code of 21 representing an inpatient hospital. The professional 
interpretation was furnished in the same payment locality as the TC was furnished. The professional interpretation of the diagnostic tests in dispute were not billed with a -26 modifier by the interpreting physician. 
Based on this information, we decided that Medicare rules for coverage of codes 94060, 94729, and 94726 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation of wheezing 
represented by code 94060, diffusing capacity represented by code 94729, and plethysmography services 
represented by code 94726 billed for date of service October 7, 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 enrollee's doctor recommends intense therapy, 
three hours daily, for the enrollee to be able to resume their regular activities due to living alone. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation 
that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350) provided on April 27, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you were advised that you 
would not be responsible for a copay because the treating provider was in-network The Plan denied your 
request. The Plan says this service is not covered under the 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 two 
dimensional (2D) oral/facial photographic image (D0350) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Impact Guard Neoprene and a Gold Anodized Color 
Package (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair and 
accessories are medically necessary to meet the enrollee's current needs. The Plan denied your request. The 
Plan says the requested accessories are not medically necessary and do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an Impact Guard Neoprene and a Gold Anodized Color 
Package (K0108x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intraoral x-
rays (D0210), and prophylaxis (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150), intraoral x-rays (D0210), and prophylaxis (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on January 19, 2022. 
 
You asked the Plan to pay for critical care services (99291). You say that the documentation supports the 
evaluation and management level of care billed. You say that these codes are payable as billed. The Plan 
denied your request. The Plan says the documentation does not support a critical care visit of 30-74 minutes 
was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
  We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate the amount of time spent rendering the critical care services. Based on this information, we 
decided that Medicare rules for coverage of critical care services (99291) have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care services (99291) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 21 additional surgical extractions (D7210 x21), removals 
of residual tooth roots (D7250), alveoloplasties in conjunction with extractions (D7310 x2), and deep 
sedation/general anesthesia services (D9222 and D9223) provided on April 14, 2022. 
 
  You asked the Plan to pay for the additional extractions, removals of residual tooth roots, alveoloplasties, and 
deep sedation/general anesthesia. You say that prior to these services being rendered, the Plan was contacted, 
and you were advised that the enrollee qualified for out-of-network benefits with your office location. The Plan 
denied your request. The Plan says the enrollee's extractions benefit has been satisfied and the frequency 
limitation has been exceeded. The Plan also says that the removals of residual tooth roots, alveoloplasties, and 
deep sedation/general anesthesia services are not covered expenses under the enrollee's dental 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 removal of residual tooth roots 
(D7250), alveoloplasty in conjunction with extractions (D7310), and deep sedation/general anesthesia (D9222 
and D9223) are not among those covered under this benefit. The contract says that extractions are limited to 
two procedure codes per calendar year. The record shows that you received 23 extractions on April 14, 2022, 
two of which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the 21 additional surgical extractions (D7210 x21), removals of 
residual tooth roots (D7250), alveoloplasties in conjunction with extractions (D7310 x2), and deep 
sedation/general anesthesia services (D9222 and D9223) provided on April 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 21, 2021, 
to November 16, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a RAP claim 
was not submitted correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The records do not show that the RAP was billed as required. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from September 
21, 2021, to November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopy (33508), three coronary venous grafts (33512), 
an ascending aorta graft with cardiopulmonary bypass (33858) and a transesophageal echocardiography 
(93314) provided on April 16, 2022. 
 
You asked the Plan to pay for an endoscopy (33508), three coronary venous grafts (33512), an ascending aorta 
graft with cardiopulmonary bypass (33858) and a transesophageal echocardiography (93314). You say that you 
do not know any of these doctors and have not had this procedure. The Plan denied your request. The Plan says 
services provided by an out of network provider are not covered under the Plan. 
 
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 endoscopy (33508), three coronary 
venous grafts (33512), an ascending aorta graft with cardiopulmonary bypass (33858) and a transesophageal 
echocardiography (93314) provided on April 16, 2022, have been met. Specifically, no medical records were 
submitted. This means that the Plan cannot determine what services, if any, were rendered on April 16, 2022. 
Therefore, we decided that the Plan does not have to pay for an endoscopy (33508), three coronary venous 
grafts (33512), an ascending aorta graft with cardiopulmonary bypass (33858) and a transesophageal 
echocardiography (93314) provided on April 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care for the enrollee is medically necessary. 
The Plan denied your request. The Plan says the records do not show the need for skilled rehabilitation services 
on a daily basis. The services the enrollee requires which is physical therapy can safely be received at a 
different setting like at home with home health, in residential care, or home with close follow-up with their 
doctor. 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 that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns (D2740 x 3). 
 
You asked the Plan to pre-approve these items. You say that dental crowns are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the dental crowns are not medically necessary. 
 
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 these dental 
items when the services are medically necessary and reasonable.  
 
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 dental items. Our reviewer says 
that the requested dental items are not medically necessary. Our physician reviewer found that the request has 
been made for core buildups and new crowns for teeth number 9, 10, and 11. The provided x-rays show only 
part of tooth number 9, and not of 10 or 11. If the photos provided are oriented such that the right teeth are seen 
on the left side of the photos, then any clear photos of any defects on these teeth are conspicuously absent.  
There may be some cosmetic issues with the teeth in question, however there is no clear damage or decay of 
the margins.  Given the lack of damage to the margins of the existing crowns, there would be no finding of necessity for the 
requested procedures. The Plan allows for crowns where there is an extensive destruction of tooth structure, 
and if there is a need to replace an existing crown due to decay. The Plan does exclude crown replacement if 
only for cosmetic issues. In this instance there has been no showing of a notable defect on any of the existing 
crowns. Given the lack of any obvious marginal defects, it is apparent the criteria for replacement crowns has 
not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dental crowns (D2740 x 3).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided from February 28, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had three emergency transports 
on this date of service. The Plan denied your request. The Plan says that the claim is a duplicate. 
 
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 the claim at issue is supported in the medical record. The medical records provided show that 
three separate ambulance trips were provided. The records indicate the trips were provided at different times, 
with different crew members, and different clinical documentation. The records do not show that the return trip 
at issue was a duplicate of a previously paid trip. Based on this information, we decided that Medicare rules for 
coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the 
ambulance transportation services provided from February 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5211) and a partial 
mandibular denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentist messed up your 
dentures in 2021. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 items or services was exhausted on date of service April 26, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5211) and a 
partial mandibular denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312, 88311) provided on October 23, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (88305, 88312, 88311) provided on October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture - flexible base (D5226) 
provided on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought you had $987.00 left of your 
allowance and you do not agree with the denied amount of $662.00. The Plan denied your request. The Plan 
says your benefit for the requested item or service $1500 dollar limit was met. 
 
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 April 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture - flexible base 
(D5226) provided on April 21, 2022.