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

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
December 16, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the panel was 
initiated by the laboratory. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The file does not show that the screening panel was ordered by the 
enrollees treating physician for a specific medical problem. Medicare does not cover this test for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening 
panel provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on March 10, 2022. 
 
You asked the Plan to pay for the oral evaluation. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they did not fall 
within your dental benefits on March 10, 2022, your new plan was effective on July 1st, 2022, and will not 
retroactively cover these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral 
evaluation (D0140) provided on March 10, 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 you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 coverage should be upheld. There is no evidence that the enrollee requires services 
that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until 
such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of 
care for any ongoing LTC 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Documentation is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. In this case, there are 
multiple plausible pathologic sources of significant pain generation. The non-radiating back pain is non-
specific to any pathologic entities. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the IRF services with medical 
documentation. The Plan denied your request. The Plan says the records do not show that the enrollee needs to 
be seen by a rehab doctor at least 3 times a week, or that they need an intensive team for their care. The 
enrollee can safely receive the services they need in other settings, for example a skilled nursing facility, home 
with home health services or home with outpatient therapy. 
 
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 patient was 
admitted for pneumonia, myocardial infarction, and coronary artery bypass grafting. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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 in a different level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myopro Upper Extremity Device (L8702). 
 
You asked the Plan to pre-approve the Upper Extremity Device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says this device 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 pre-approve the Upper Extremity Device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found current clinical guidelines designate robotic therapy to be of uncertain utility 
compared with dose-matched conventional upper limb exercise therapies with unproven benefit in the home 
environment. 
 
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 Upper Extremity Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Myopro Upper Extremity Device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the 
pneumatic compression device have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total parenteral nutrition (TPN). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TPN 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not show that 
you have tried and failed enteral nutrition or that it would worsen your gastrointestinal (GI) tract dysfunction. 
There is no documentation of a condition that significantly impairs the absorption of nutrients or disease of the 
stomach and/or intestine that impairs the ability of nutrients to be transported through and absorbed by the GI 
system. There is no documentation that the your is a permanent impairment. The criteria for coverage are not 
met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total parenteral nutrition (TPN).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the dentist made your dentures. You say that 
you found out it would not be covered. You also say that you need these dentures. The Plan denied your 
request. The Plan says upper partial denture is covered once every 5 plan years. The Plan also says that the 
frequency limit has been reached. 
 
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 and partial denture is listed as covered, 
the frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for the 
upper partial denture you received on October 15, 2019. Therefore, we decided that the Plan does not have to 
pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (D6010) for tooth #5 and sales tax 
(D9985) for this service. 
 
You asked the Plan to pre-approve implant services. You say that this dental implant is medically necessary. 
The Plan denied your request. The Plan says these services are not covered by your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental implant (D6010) for tooth #5 and sales tax (D9985) for this service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you would like these services covered. The 
Plan denied your request. The Plan says services must be provided by a participating general dentist. 
 
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 covered 
dental services when the services are provided by a participating general dentist.  
 
We looked at the file and Medicare rules. Services provided by an oral surgeon are not covered. Based on this 
information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve dental services provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a provisional crown (D2799) and a prefabricated post 
and crown (D2954). 
 
You asked the Plan to pre-approve a provisional crown and a prefabricated post and crown. You say that these 
services are medically necessary. The Plan denied your request. The Plan says dental x-rays were not provided. 
 
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 a provisional crown (D2799) and a 
prefabricated post and crown (D2954) have been met. The dentist has failed to send in dental x-rays needed to 
verify if the requested services are medical necessity. Therefore, we decided that the Plan does not have to pre-
approve a provisional crown (D2799) and a prefabricated post and crown (D2954).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to waive the deductible and apply the $40 copayment for the lab services 
provided on February 28, 2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that the cost should have been covered 
in full. The Plan says that the correct amount was applied to your deductible. 
 The Plan says that you must pay the remaining $149.23 to meet your deductible for the lab services. Based on 
the Plan contract, however, lab services are not subject to the deductible amount. In this case, you cannot be 
asked to pay more than a $40 copayment for lab services at an outpatient hospital. Therefore, we decided that 
the Plan does has to waive the deductible and apply the $40 copayment for the lab services provided on 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for audiology services you provided on September 17, 2021. 
 
You asked the Plan to pay for audiology services. The Plan denied your request. The Plan says prior approval 
was not obtained. Some services require prior approval as listed in the benefits chart in Chapter 4 of the 
Evidence of Coverage. Exceptions are emergency care, out-of-area urgently needed care, or renal dialysis. 
 
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 did not pre-approve the 
services 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 audiology services you provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) and simple repair of 
superficial wounds of face (12013, 12011) billed for date of service October 31, 2021. 
 
You asked the Plan to pay for an emergency department visit and simple repair of superficial wounds of face. 
You say that you have provided records to support the services billed. The Plan denied your request. The Plan 
says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The case record shows that the services at issue were billed with two conflicting diagnosis codes because one 
of the codes indicated laterality and the other did not specify laterality. Additionally, we have confirmed that 
code 12011 is a column II code to column I code 12013 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) and simple repair of 
superficial wounds of face (12013, 12011) billed for date of service October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel this service should be covered. You say 
that the previous one was complete before you were having issues. You also say that you needed to have 
dentures. The Plan denied your request. The Plan says that claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a full mouth x-ray or panorax is 
listed as covered once every 36 months, the frequency limit has been exceeded. The record shows that the Plan 
paid for a panorax that you received on July 17, 2020. Therefore, we decided that the Plan does not have to pay 
for the complete series x-ray (D0210) provided on April 12, 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 enrollee is currently still intubated 
with multiple comorbidities that require LTACH level of care. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The Plan has approved ongoing care in the current acute care setting. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device cleaning 
supplies provided on January 30, 2022, by a supplier not enrolled in the Medicare program. 
 
You asked the Plan to pay for CPAP cleaning supplies. You say that the provider at issue was not out-of-
network. The Plan denied your request. The Plan says rules for payment have not been met because the 
supplier at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure 
(CPAP) device cleaning supplies provided on January 30, 2022, by a supplier not enrolled in the Medicare 
program.