Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays and unspecified adjunctive procedures () 
provided on August 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 August 16, 2021. 
Therefore, we decided that the Plan does not have to pay for periapical x-rays and unspecified adjunctive 
procedures () provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incomplete endodontic therapy (D3332) and a pulp 
vitality test (D0460) provided by a participating provider on June 3, 2022. 
 
You asked the Plan to pay for an incomplete endodontic therapy and a pulp vitality test. You say that you 
believe the Plan should pay for these services. The Plan denied your request. The Plan says the dental services 
provided are not covered 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 an 
incomplete endodontic therapy (D3332) and a pulp vitality test (D0460) provided by a participating provider on 
June 3, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee has not required prolonged mechanical ventilation. There is no 
documentation of intubation. There is no documentation of multiple unsuccessful weaning attempts. The 
documentation does not support the safe and secure placement of a tracheostomy tube. The enrollee is 
receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
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 is unable to tolerate intensive rehabilitation as her ability to tolerate an 
upright posture is severely limited. Her cognitive impairment also limits her ability to benefit from intensive therapy. The IRF is not a medical step down unit for continuation of hospitalization. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
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 the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no data that describes proton therapy as necessarily superior to photon therapy with respect 
to outcomes for skull tumors, particularly when treated to a dose of 50-50.4 Gy with conventional fractionation 
(a dose commonly used for meningiomas and offered to this patient with angiosarcoma) tumors. In summary, 
proton therapy in and of itself is not experimental. Any potential benefit over non proton based IMRT is 
investigational. Proton therapy can be considered medically necessary for scalp/skull tumors when the need is 
sufficiently supported with a plausible dosimetric rationale. Otherwise, proton therapy would not be furnished 
in accordance with accepted standards of medical practice. 
 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy for the enrollee.
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 an IRF stay is medically necessary. The Plan denied 
your request. The Plan says you do not meet 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 intensive rehabilitation or frequent physiatry oversight to recover 
from an uncomplicated hip fracture repair. You are functioning at a routine level commonly seen post -hip fracture repair in a frail elder and standard post-acute rehabilitation services at levels of care other than IRF are 
sufficient to meet your needs 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 30901 provided to the 
enrollee on December 3, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a bilateral surgical procedure must be reported with one unit of service and modifier 50 (bilateral 
modifier) on one claim line. 
 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 30901 is "Control nasal hemorrhage, anterior, simple 
(limited cautery and/or packing) any method." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider performed simple 
nasal hemorrhage control on right and left side. Per CPT guidelines "(To report bilateral procedure, use 30901 
with modifier 50)."  In this case, service was incorrectly billed. 
 
We looked at this coder'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 an additional unit of procedure code 30901 provided to the enrollee on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus DPYD (dihydropyrimidine dehydrogenase) test 
(81232) provided on June 30, 2022. 
 
You asked the Plan to pay for the services. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says this test has not been cleared or approved by the Food and Drug Administration 
(FDA) and is not a companion diagnostic for any therapy. 
 
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 the documentation does not support that the Tempus DPYD (dihydropyrimidine dehydrogenase) 
testing was medically reasonable and necessary for the enrollee in this case. There is no evidence that Tempus DPYD (dihydropyrimidine dehydrogenase) testing has FDA approval or clearance as a companion in vitro 
diagnostic, and an FDA-approved or FDA-cleared indication for use in that patient's cancer. 
 
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 a Tempus DPYD (dihydropyrimidine dehydrogenase) test (81232) provided on June 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 physical therapy visits have been met. 
Medical records were requested and not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stability biologics physio allograft. 
 
You asked the Plan to pre-approve stability biologics physio allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 stability biologics physio allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found stability biologic allograft is experimental in spine surgery. More research 
is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stability biologics physio allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stability biologics physio allograft.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that that the coverage 
criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that you have had a significant functional decline from your baseline level of function and would benefit 
from the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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 waive the cost share for all the items and services, provided from 
December 8, 2021, to May 16, 2022. 
 
You asked the Plan to waive the cost share for the items and services. You say that the Plan should cover all 
expenses. 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 enrollees must pay 
20% coinsurance for in-network Part B drugs, a $335 copayment for in-network outpatient surgery services, 
and a $40 copayment for in-network specialists office visit. 
 You have been asked to pay up to a $335 copayment for the outpatient surgical services received from 
December 8, 2021, to May 10, 2022. You have also been asked to pay 20% coinsurance of the allowed amount 
for Part B drugs received from December 8, 2021, to March 7, 2022. You have also been asked to pay up to a 
$40 copayment for each specialist office visit received from February 9, 2022, to May 16, 2022. 
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
20% 
COINSURANCE 
 
COPAYMENT 
December 8, 2021 67028 $288.64  $288.64 
December 8, 2021 C9257 $8.80 $1.76  
CLAIM TOTAL    $290.40 
January 3, 2022 67028 $303.37  $303.37 
January 3, 2022 J7312 $1,119.98 $279.99  
CLAIM TOTAL    $583.36 
February 7, 2022 67028 $303.37   
February 7, 2022 C9257  $6.21 $1.24 
CLAIM TOTAL    $304.61 
February 9, 2022 99204 $134.13  $40.00 
CLAIM TOTAL    $40.00 
March 07, 2022 67028 $303.37  $303.37 
March 07, 2022 J7314 $6,823.24 $1,364.65  
CLAIM TOTAL    $1,668.02 
April 11, 2022 99214   $40.00 
CLAIM TOTAL    $40.00 
May 3, 2022 66821 $478.82  $335.00 
CLAIM TOTAL    $335.00 
May 10, 2022 66821 $478.82  $335.00 
CLAIM TOTAL    $335.00 
May 16, 2022 98968 $33.79  $33.79 
CLAIM TOTAL    $33.79 
 
The Part B drug falls within the Medicare Part B prescription drugs benefit category. The outpatient surgical 
services fall within the outpatient surgical services benefit category, and the specialist office visit falls within 
the physician/practitioner services, including doctors office visits. 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 
cost share for all the services, provided from December 8, 2021, to May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on May 
4, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 74178: 
 
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed 
by contrast material(s) and further sections in one or both body regions 
 
HCPCS G0463: 
 Hospital outpatient clinic visit for assessment and management of a patient 
 
HCPCS Q9967: 
 
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the report of the computed 
tomography angiography (CTA) describes the use of 75 low osmolar contrast for IV injection which is the 
usual amount. Perhaps the additional charge for contrast is related to the use of the agent for oral 
administration. This is a common use for the low osmolar contrast agent, but such usage must be included in 
the report to justify reimbursement and that was not done in this case. Absent such documentation the charge 
for additiional contrast usage should be denied. 
 
We looked at this coder'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 outpatient hospital services provided to the enrollee on May 4, 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 the enrollee received physical and occupational therapy. The enrollee was at 
modified independent stand by assist level with functional mobility including gait to 100 feet and required 
varying assist with activities of daily living skills. The enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (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.