Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified. 
 
You asked the Plan to pre-approve the services. You say that this is medically necesasry. The Plan denied your 
request. The Plan says the requested item is not medically necessary. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you only had a brief course of physical therapy. The criteria for the amount of therapy have not been 
met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle 
groups, any type, complete system, not otherwise specified.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medical;y necessary. Our physician reviewer found provided records document chronic 
respiratory failure due to idiopathic pulmonary fibrosis. Records document that the home ventilator is being 
requested for use with very low set tidal volumes (150 to 200 mL) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume assured pressure support and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 1, 2022. 
 
You asked the Plan to pay for the refraction. You say that you are supposed to receive a diabetic check once a 
year and thought insurance covered it. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the refraction is not among those 
covered under this benefit. The record shows the refraction was performed during a medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the refraction provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunoglobulin light chains provided to the enrollee on 
April 7, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service is experimental and non-covered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is deemed to be experimental and investigational. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for immunoglobulin light chains provided to the enrollee on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the resin-based 
composite (D2391) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. 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 the Plan has paid $4,000 towards dental services which exhausted this benefit. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) and the resin-based composite 
(D2391) provided on July 12, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 45380-XS billed for date of service September 14, 
2021. 
 
You asked the Plan to pay for procedure code 45380-XS. You say that this code is separately payable because 
the service occurred on a separate lesion/location and a different technique/instrument was used. The Plan 
denied your request. The Plan says that code 45380-XS is a bundled code and not separate payment is allowed. 
 
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 
45380-XS is a column II code to column I code 45385; however, 45380-XS was billed with a modifier. 
Specifically, code 45380 was billed with an XS modifier.  This modifier indicates that the service was 
performed on a separate structure, and it is therefore distinct from the primary procedure.  
 
The Plan has failed to address the application of this modifier at all in the limited case file it submitted to us.  
The Plan has not claimed (nor has it provided evidence to the effect of) this modifiers inappropriate usage.  
The Plan has not provided any medical records, so we cannot determine how or why the Plan made the 
decision that the modifier was inappropriate in this case. Appending of modifier XS would typically make the 
column II code (in this case, 45380) separately payable.  The burden is on the Plan to show why its denial was 
appropriate. Because the Plan has failed to provide medical records, any analysis of its determination of the 
appropriateness of the use of modifier XS, or even any citation to any rule upon which its denial was based, we 
find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for procedure code 
45380-XS billed for date of service September 14, 2021.  
 
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 the eyewear provided on April 19, 2022. 
 
You asked the Plan to pre-approve the eyewear. You say that you received new glasses and did not want the 
scratch-resistant coating. The Plan denied your request. The Plan says the benefit was exhausted. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan will provide reimbursement for up to a $175 allowance every calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $175 towards your eyewear which 
exhausted the benefit. This means you are responsible for any amount over the $175 for the eyewear. Based on 
this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the eyewear provided on April 19, 2022.
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 this is medically necessary. The Plan 
denied your request. The Plan says there is no benefit of the enrollee to be moved to a long-term acute facility. 
 
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 that in this case, the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH(e.g., multiple and prolonged intravenous therapies, monitoring of 
significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, 
complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that 
are not available at the acute care hospital or the skilled nursing facility. The requested treatments are not 
medically necessary at the LTACH level of care. The enrollee continues to require care at an acute hospital. She can receive further care at the current acute care hospital or a lower level of care when deemed 
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemotherapy combination of Irinotecan, Kanjinti, 
and Keytruda. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee is allergic to other drugs. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 the drugs. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found that this combination of drugs is not evidence-based. This is not a recognized regimen for the enrollee's diagnosis. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a chemotherapy combination of Irinotecan, Kanjinti, and Keytruda.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
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 the enrollee has stabilized medically and is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The 
enrollee is medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube.  The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she 
can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the chest provided on April 
26, 2022. 
 
You asked the Plan to waive the copayment for a CT scan of the chest. You say that you are already paying 
$148.50 for a CT scan of the chest, which you were told in a letter that it should not have been billed. You say 
that you believe this is a coding issue and would like it to be reversed. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for all complex imaging except a mammography.  
 
 
 
  You have been asked to pay a coinsurance of $148.50, which is 20% of the allowed amount for a CT scan of 
the chest ($742.50 allowed x 20% = $148.50). This item/service falls within Outpatient Diagnostic Tests 
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 copayment for a CT scan of the chest provided 
on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) 
provided on June 30, 2022, and periodontal scaling and root planing - four or more teeth per quadrant (D4341 
x4) provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you transferred from one office location to 
another and were informed you had to be treated as a new patient even though you were already a current 
patient. 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 intraoral - periapical first radiographic image (D0220) was exhausted on the appeal 
claim of June 30, 2022, and the root planing - four or more teeth per quadrant (D4341) was exhausted on 
September 2, 2020. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first 
radiographic image (D0220) provided on June 30, 2022, and periodontal scaling and root planing - four or 
more teeth per quadrant (D4341 x4) provided on July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare guidelines for 
admission to the IRF.  The Plan denied your request. The Plan says an intensive rehabilitation program is not 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femur after a fall.  Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided a in a different level of care. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 November 4, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete x-rays (D0210) and the comprehensive exam 
(D0150) provided on July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not believe that you met the frequency 
limit. The Plan denied your request. The Plan says your benefits for the complete x-rays (D0210) and the 
comprehensive exam (D0150) have 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 benefits for the complete x-rays (D0210) and the comprehensive exam (D0150) were exhausted on 
date of service April 7, 2022. Therefore, we decided that the Plan does not have to pay for the complete x-rays 
(D0210) and the comprehensive exam (D0150) provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 13, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on December 13, 2021.