Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 8 PT visits. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 an additional 8 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 8 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 8 physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 19, 2021 and billed under code 93880.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76536 and 93880. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 19, 2021 and billed under code 93880.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that it is more cost effective to add 
this medically necessary component now to the chair than in the future changing the entire base. The Plan 
denied your request. The Plan says a seat elevator does not service a primary medical purpose and is statutorily 
non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on September 13, 2021. 
 
You asked the Plan to pay for a shingles vaccine under Medicare Part B. You say that this vaccine was offered 
like all the others that are covered by the Plan. The Plan denied your request. The Plan says the shingles 
vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine 
under Medicare Part B. The Plan follows the same rules. Therefore, we decided that the Plan does not have to 
pay for a shingles vaccine provided on September 13, 2021.  
 
Benefits for a shingles vaccine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 home health physical therapy (PT) visits. 
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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 you have been receiving home health 
services for weakness and unstable gait since December 3, 2021. The records do not document any acute or 
unstable medical conditions or changes in medication treatment that would require further skilled therapy visits 
beyond what has been approved by the Plan. You are walking with a walker with assistance and need 
supervision for transfers. There are no medical notes from your treating physician documenting an order or 
need for additional PT. The 15 visits 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 15 home health physical therapy (PT) visits.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. 
 
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 pay for the inpatient services provided from January 26, 2021, through January 31, 2021.
You asked the Plan to pay for the inpatient services. You say that based on the clinical impression by the treating physician, a diagnosis of sepsis was made with evidence of organ dysfunction caused by a dysregulated host response to an infection. You say that the principal diagnosis A41.9 is supported in the medical record and the denial should be overturned. The Plan denied your request. The Plan says the records do not support the diagnosis code A41.9.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services with A41.9 defined as sepsis, unspecified. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the primary diagnosis code A41.9. Our physician reviewer found that although sepsis was documented in the physicians' notes, there was insufficient evidence of life-threatening organ dysfunction caused by a dysregulated host response to infection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from January 26, 2021, through January 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 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. 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 18, 2021.
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says the POS code is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aducanumab-avwa (Aduhelm). 
 
You asked the Plan to pre-approve Aduhelm. The Plan denied your request. The Plan says the requested 
medication not reasonable or 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 Aduhelm. Our reviewer says that 
Aduhelm does not meet the coverage criteria. Our physician reviewer found the documentation does not 
support that the Aducanumab-avwa (Aduhelm) is medically reasonable and necessary for the enrollee. The 
enrollee's Mini-Mental State Exam (MMSE) was scored 28/30 which is consistent with normal cognition. Our 
reviewer found that the magnetic resonance imaging (MRI) in this case suggests the presence of 
cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. It has not been 
shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate 
alternatives for this enrollee. Our physician reviewer also found that the documentation does not support that 
Aduhelm is reasonably expected to be safe and effective for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aducanumab-avwa (Aduhelm).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code
81455 are denied as not medically necessary.
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059) provided 
September 22, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you 
feel that at least the crown should be covered. The Plan denied your request. The Plan says implant services are 
not covered under your 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 pay for the custom fabricated abutment - includes placement (D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059) 
provided September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2791), prefabricated post and core in 
addition to crown (D2954), and endodontic therapy (D3320). 
 
You asked the Plan to pre-approve the crown, prefabricated post and core, and endodontic therapy. The Plan 
denied your request. The Plan says these services are not covered benefits under your plan. 
 
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 
crown (D2791), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3320).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on October 22, 2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you had to keep going back to 
the hospital for the same condition after being discharged. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 a $120 
copayment for emergency care.  
You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on 
October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that this oral evaluation denied in error. You also say 
that you did not exceed your limit. The Plan denied your request. The Plan says 2 exams and cleanings are 
covered per year. The Plan also says that the frequency limit has been exceeded. 
 
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 2 oral exams are covered per year, 
the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on 
April 7, 2021, and May 10, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam 
(D0120) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 2, 3, 14, and 29. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs to have these teeth 
replaced with dental implants to restore masticatory function. The Plan denied your request. The Plan says 
dental implants and all related services are 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant placements are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) for teeth # 2, 3, 14, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive oral 
evaluation (D0150) provided by a participating provider on November 22, 2021. 
 
You asked the Plan to pay for intraoral imaging, and a comprehensive oral evaluation. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for these services 
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. The Plan covers intraoral 
imaging once every 36 months, and a comprehensive oral evaluation once every six months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of intraoral imaging, and a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210), and a comprehensive oral evaluation 
(D0150) provided by a participating provider on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-durometer socket insert addition. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that no more than two of the same socket inserts (L5654, 
L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at 
the same time. 
 
We looked at the file and Medicare rules. The file shows that you have been approved for two socket inserts. 
The socket insert described by code L5665 cannot be approved as a third socket insert. Therefore, we decided 
that the Plan does not have to pre-approve a multi-durometer socket insert addition.
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 the complete maxillary denture. You say that you have dental benefits and 
need the upper denture. You also say that your dental benefit covers up to $1,500.00 and you would like to 
know why this service is not covered. The Plan denied your request. The Plan says this service is not covered 
under your plan. 
 
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 
complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement, primary and permanent teeth 
(D3221) provided October 27, 2021. 
 
You asked the Plan to pay for the pulpal debridement. You say that the preparation process was necessary prior 
to applying the crown and should be covered under the crown approval. The Plan denied your request. The 
Plan says this service is not covered under your 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 the pulpal 
debridement, primary and permanent teeth (D3221) provided October 27, 2021.