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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to improve her quality of 
life. The Plan denied your request. The Plan says that based on Medicare guidelines, the requested IRF services 
do not meet the requirements for approval. 
 
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 the enrollee has a neurological and IRF compliant diagnosis. Clinical documentation supports need for 
close medical supervision on an inpatient basis with a multi-disciplinary approach to rehabilitation care. 
Evaluating therapists recommend intense rehabilitation with all three therapy disciplines (physical therapy, 
occupation therapy and speech-language pathology). Clinical documentation supports that the enrollee would 
benefit from and be able to participate in an intense rehabilitation program. 
 
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 
acute inpatient rehabilitation facility (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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on April 8, 2021. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this because it 
was covered before. The Plan denied your request. The Plan says the rendering dentist has opted-out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until July 12, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on October 22, 2021.
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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology 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
testing was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of uterine
cancer. The limited documentation does not support that the alternative laboratory or clinical tests to
definitively diagnose the enrollee's disorder or identify the condition are unavailable or results are clearly
equivocal. Additionally, it has not been shown that the number of genes or tests were reasonable and necessary
to obtain the necessary information for therapeutic decision making. This test analyzes 324 genes as well as
genomic signatures including microsatellite instability and tumor mutational burden. The testing was 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 pay for the FoundationOne CDx testing rendered on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower overdenture (D5863 and 
D5865). 
 
You asked the Plan to pre-approve the complete upper and lower overdenture (D5863 and D5865). The Plan 
denied your request. The Plan says the services 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 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 pre-approve the 
complete upper and lower overdenture (D5863 and D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete denture. You say that you lost your previous denture and need 
new ones. The Plan denied your request. The Plan says you previously received a complete upper denture in 
February of 2019. Dentures are covered once every 60 months, and it has been less than 60 months since you 
last received a denture for the upper jaw. 
 
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. The Plan covers dentures once 
every 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the 
denture is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation (RFA) for 
the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records needed include details of an exam done by your doctor, the latest office note, 
blood tests, prior treatment, and/or picture studies such as plain x-ray. 
 
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 the enrollee only had one set of diagnostic medial branch blocks, and has not undergone a prior RFA 
procedure at the same level. 
 
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 cervical facet joint radiofrequency ablation (RFA) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on November 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel.  
 
We looked at the file and Medicare rules. The services in this case were provided by a therapy assistant without 
direct physician or NPP supervision. 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 the therapy 
services provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of all 
four quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the periodontal scalings and root 
planings are medically necessary. The Plan denied your request. The Plan says this service is only covered 1 
time in a 3-year time period. The Plan also says that you have already had this service done in that time 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal scaling and root planing 
(D4341) is limited to once per quadrant, per 3 years. The record shows that the enrollee received periodontal 
scalings and root planings (D4341) of two quadrants on July 28, 2021, and periodontal scalings and root 
planings (D4341) of the remaining two quadrants on August 18, 2021 and the enrollee's periodontal scaling and 
root planing (D4341) benefit for all four quadrants has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve periodontal scalings and root planings (D4341) of all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that you lost your upper denture and 
cannot eat well without it. The Plan denied your request. The Plan says this service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is 
limited to one procedure every five plan years. The record shows that you received a complete maxillary 
denture (D5110) on January 10, 2019 and your complete maxillary denture (D5110) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture 
(D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 23, 24, 25, and 26 and 
anatomical crown exposures (D4231) for the lower left and lower right quadrants. 
 
You asked the Plan to pre-approve the crowns and anatomical crown exposures. You say that you were told no 
prior authorization or criteria was mandated for crowns. The Plan denied your request. The Plan says there is a 
lack of documentation showing that more than half of each of the teeth being requested is damaged due to 
decay and injury. The Plan also says that the request for anatomical crown exposure for the lower left and 
lower right quadrants are not necessary if crowns are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns 
and anatomical crown exposures when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns and anatomical crown 
exposures. Our reviewer says that the documentation provided does not meet the criteria for coverage for the 
crowns and anatomical crown exposures. Our physician reviewer found the documentation does not indicate 
significant coronal breakdown due to caries or fracture of tooth #'s 22, 23, 24, 25, and 26 to warrant crown 
restorations and anatomical crown exposure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and anatomical crown exposures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 23, 24, 25, and 26 and 
anatomical crown exposures (D4231) for the lower left and lower right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rubber damming (D3910) and fitting and placing a post 
in a tooth (D3950) for tooth # 10. 
 
You asked the Plan to pre-approve the dental services. You say that these services are required as pre-work for 
the treatment that you need. The Plan denied your request. The Plan says rubber damming and fitting and 
placing a post in a tooth are not listed as covered 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 rubber damming and 
fitting and placing a post in a tooth are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve rubber damming (D3910) and fitting and placing a post in a tooth 
(D3950) for tooth # 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete lower denture (D5120) provided on 
January 26, 2022. 
 
You asked the Plan to pay more for the complete lower denture (D5120). You say that you were informed your 
complete set of dentures would not cost more than $1,700. The Plan denied your request. The Plan says the 
calendar year maximum 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
$2,500 for supplemental preventive and comprehensive dental services every year. The Plan paid $2,500 
toward the complete upper and lower denture received on January 26, 2022, which exhausted your benefit. You 
are responsible for the remaining amount. Therefore, we decided that the Plan does not have to pay more for 
the complete lower denture (D5120) provided on January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nail debridement procedure provided on January 18, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nail debridement. You say that your provider receives a list of patients who 
require treatment and provides services to all of them since there is no in-network doctor available in the 
facility. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 a nail debridement procedure provided on January 
18, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical repair (closure) procedures on the 
integumentary system 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are 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 requested services. Our physician 
reviewer found that the enrollee has scarring in the left lower quadrant of his abdomen. He had previous 
panniculectomy and liposuction. He reported a previous abscess that recurred, as well as some tenderness with 
exercise. The exam was notable for a mature scar measuring 2 x 7 cm, with no evidence of an abscess, and 
significant skin laxity. The available documentation does not support that the proposed surgery is medically 
reasonable and necessary for the enrollee in this case. The clinical documentation does not support that he has a 
functional deficit. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical repair (closure) procedures on the integumentary system
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiac risk assessment genetic screening testing coded as 
81404, 81479 provided November 20, 2020. 
 
You asked the Plan to pay for the genetic screening. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says this test does not meet Medicare coverage criteria. The documentation does not indicate 
how the test results will assist in managing the enrollee's condition. 
 
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. 
 
The test at issue in this appeal, the genetic screening, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for a cardiac risk assessment genetic screening testing coded as 81404, 81479 provided November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth provided March 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extraction provided OON. You say that you were not aware that this 
would not be covered. The Plan denied your request. The Plan says this service is not covered because the 
provider is OON. 
 
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. The Plan covers the tooth 
extraction provided OON. when the services are provided in-network. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction provided OON have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical removal of erupted tooth provided March 11, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on January 28, 2022, billed with code 70450. 
 
You asked the Plan to pay for the CT interpretation as billed. You say that this should be paid since multiple 
services were rendered, regardless of how the claim was billed. The Plan denied your request. The Plan says 
the Column 2 code does not have a PTP modifier to allow separate payment. 
 
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 70450 
is a column II code to column I code 70496. 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 the interpretation of the computed tomography (CT) scan of the 
head provided on January 28, 2022, billed with code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 retainer crowns (D6740) and pontic (D6245). 
 
You asked the Plan to pre-approve a fixed bridge. You say that you need this service. The Plan denied your 
request. The Plan says a fixed bridge is excluded from coverage. 
 
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 fixed bridge is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 2 
retainer crowns (D6740) and pontic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor/flash monitoring 
system 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the records do not support that the 
enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that every six (6) months following the initial 
prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee has had have had 
an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan within. The records show that the last office visit was May 14, 2021. Based on this information, 
we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor/flash monitoring system