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

 
We decided that the Plan has to pay for the inpatient readmission and stay provided from March 22, 2022, to 
April 1, 2022. 
 
You asked the Plan to pay for the inpatient readmission and stay. The Plan denied your request. The Plan says 
that this new hospital stay cannot be approved as a separate stay. The Plan also says that the hospital should 
include all expenses for this admission with the last hospital admission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient readmission and stay. Our 
reviewer says that the readmission was medically necessary. Our physician reviewer found the readmission did 
not result from a premature discharge from the same hospital.  
 
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 inpatient readmission and stay have been met. Therefore, we decided that 
the Plan has to pay for the inpatient readmission and stay provided from March 22, 2022, to April 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. 
 
 
 
 
 
 
  
 
 The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we 
decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that the services were part of the ordering 
provider's plan of care, so your facility should not be penalized for not obtaining authorization for these 
services. The Plan denied your request. The Plan says unauthorized, non-plan services are not covered. 
 
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 provider in this case is not a network provider with the Plan. The authorization only covers services from 
the patient's physician, not lab services provided at your facility. 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 lab services provided on February 2, 2022 by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections. 
 
You asked the Plan to pre-approve Orthovisc injections. The Plan denied your request. The Plan says the 
enrollee has excess fluid in the knee but has not yet tried aspiration and continued to have symptoms. 
 The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions listed in the Medicare rules section of this letter are met. 
 
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 Orthovisc injections. Our reviewer says 
that Orthovisc injections are not reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of knee pain, has a history of previous meniscal tear and has an effusion that has not been aspirated. 
A magnetic resonance imaging (MRI) is pending to confirm the diagnosis. Our reviewer found that the Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that this care is medically necessary for your 
condition. The Plan denied your request. The Plan says there are in-network providers available to provide the 
care you need. 
 
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 
office visit services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document the enrollee is very 
limited functionally, improvement in the enrollees functional status does not appear to be predictable in a 
reasonable time frame to necessitate daily skilled therapy services; part time therapy services in a long-term 
care facility setting does not appear to be inappropriate in this case. Given the enrollee's reported poor 
progress" towards rehab goals and her cognitive deficits, services in a long-term care facility on a part time 
basis appear appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (00300) provided on February 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The submitted documentation does not show that 
these services were billed on another claim that was processed by the Plan. Based on this information, we 
decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has 
to pay for the services (00300) provided on February 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that you are requesting Keytruda for subsequent 
treatment of the enrollees metastatic adenocarcinoma of the lung. The Plan denied your request. The Plan says 
medical studies have not proven that this drug is helpful when the enrollee has tried but not had a positive 
response to another anti-PD1 drug (a medication that blocks a certain protein to help the body's immune system 
fight cancer). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 record indicates that the enrollee has a diagnosis of stage IIIB adenocarcinoma PDL-1 positive. The 
record indicates that the enrollee had disease progression on Nivolumab. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied.  
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 Keytruda (CPT code J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CGM supplies. 
 
You asked the Plan to pre-approve the CGM. You say that you need this CGM to manage your blood sugars 
better. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you are not insulin treated with 
multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) 
pump with frequent adjustments based on your blood sugar readings. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CGM supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for D0120 (Periodic oral evaluation, established patient), 
D0272 (bitewings - two radiographic images) and D1110 (prophylaxis  adult) on April 12, 2022, and D2393 
(Resin-based composite - three surfaces, posterior) and D2392 (Resin-based composite - two surfaces, 
posterior) on April 13, 2022. 
 
You asked the Plan to pay more for the dental services. 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 D0120 (Periodic oral evaluation, established 
patient), D0272 (bitewings - two radiographic images) and D1110 (prophylaxis  adult) on April 12, 2022, and 
D2393 (Resin-based composite - three surfaces, posterior) and D2392 (Resin-based composite - two surfaces, 
posterior) on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic-porcelain/ceramic (D6245) tooth #30 and 
retainer crown - porcelain/ceramic (D6740) tooth #31 
 
You asked the Plan to pre-approve dental services. You say that your bridge fell out and you need to get it 
fixed. The Plan denied your request. The Plan says the service requested exceeds the maximum count allowed 
per period. 
 
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. This dental services benefit 
includes bridge procedure every five plan years per tooth. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously had bridge work done on January 
29, 2019. Therefore, these benefits are exhausted for five plan years. Therefore, we decided that the Plan does 
not have to pre-approve pontic-porcelain/ceramic (D6245) tooth #30 and retainer crown - porcelain/ceramic 
(D6740) tooth #31.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 76705. The Plan denied your request. The Plan says payment for 
code 76705 is bundled into payment for code 93976.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel rendered 
on March 9, 2022. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the testing at issue is not approved or 
cleared by the Food and Drug Administration (FDA), as required by the Medicare rules. There is not 
documentation to support that the testing was reasonable and medically necessary for the enrollee. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xT Solid Tumor and Heme CGP Panel rendered on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stress echocardiogram (CPT code 93551). 
 
You asked the Plan to pre-approve the stress echocardiogram. You say that the enrollee experiences shortness 
of breath and palpitations. You state the enrollee recently had a stress test with abnormal results. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because their records show 
the enrollee does not have any cardiac symptoms, any cardiac history, or any other of the above indications. 
 
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 stress echocardiogram. Our 
physician reviewer found there is no documentation that the stress echocardiogram at issue in this case meets 
Medicare criteria for medically reasonable and necessary. Provided records do not document any acute cardiac 
symptoms. A stress test from August 19, 2022, was reported as normal with no chest pain or electrocardiogram 
(EKG) changes and a "good" blood pressure response to exercise; the enrollee achieved 10.1 METs. 
 
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 stress echocardiogram have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the stress echocardiogram (CPT code 93551).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (CPT code D5213) and 
mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you are asking to reinstate the enrollee's 
denture benefits because the enrollee's gums are deteriorating, and their teeth are rotten. You state the enrollee 
will need extractions and the bridge will no longer hold. The Plan denied your request. The Plan says the 
enrollee exhausted their benefit frequency limit. 
 
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 enrollee's dental benefits provide coverage for dentures once every five years. The Plan paid for upper and 
lower partial dentures on August 7, 2018, through the delegated dental vendor for date of service July 16, 2018. 
The enrollee is not eligible for a new set of dentures until July of 2023. Therefore, we decided that the Plan 
does not have to pre-approve maxillary partial denture (CPT code D5213) and mandibular partial denture 
(D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service November 9, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says procedure 
code 99000 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. 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 procedure code 99000 billed for date of service November 9, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the heart without contrast with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that Medicare does not cover the requested study for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that while the enrollee has 
no current cardiac symptoms, aside from the mitral regurgitation. A review of the records showed a low dose 
computed tomography (LDCT) exam in 2019 where moderate coronary atherosclerotic calcification was noted. 
Given the positive CT results and the diagnosis of mitral regurgitation, the request for CT coronary calcium 
scoring should be approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the heart without contrast with quantitative evaluation of coronary calcium.  
 
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.