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

 
We decided that the Plan does not have to pay for the crown repair (code D2980) you received on November 
30, 2021. 
 
You asked the Plan to pay for the crown repair. You say that this crown repair was needed to complete a root 
canal.  In addition, it should be considered a restorative service and should be covered. The Plan denied your 
request. The Plan says this is not a covered service under 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.  Your dental plan only covers 
certain services.  Crown repairs are not listed as a covered service.  A crown repair is not a filling.  In addition, 
just because the crown repair was needed in order for a root canal to be performed does not mean that the Plan 
is obligated to cover it. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown repair 
(code D2980) you received on November 30, 2021.
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 you are ready to be admitted to the inpatient 
rehabilitation hospital. The Plan denied your request. The Plan says authorization denied because the IRF care 
is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 21, 
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 this testing is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. 
 
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 genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making 
in the clinical management of the patient and will be denied automatically as not medically necessary. The review has determined that the services at issue in this case are not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy and related services provided to the 
enrollee on October 11, 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 the denied codes remain not supported. 
 
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 52330: 
 
Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus 
 
CPT 52344: 
 
Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) 
 
CPT 52352: 
 
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral 
catheterization is included) 
 
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 in terms of CPT 52330, per CCI edits, 
stone manipulation is rarely done without a stent, and the code for a stent is CPT 52356, which in this case 
would include CPT 52330. In terms of CPT 52344 and CPT 523552, treatment of ureteral stricture would be 
performed if needed in order to performed with description for CPT 52356, and therefore would not be 
reported separately.   
 
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 cystourethroscopy and related services provided to the enrollee on October 11, 2021.
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 you want IRF care to improve your quality of life 
and get your strength back. The Plan denied your request. The Plan says criteria for admission to the IRF 
setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of 
care. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 you require IRF care to recover successfully from 
the fall you had. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxervate Sol for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxervate Sol for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 pressure-reducing support surface. 
 
You asked the Plan to pre-approve the Group 2 support surface. You say that this is needed due to history of 
pressure ulcers. The Plan denied your request. The Plan says there are no current pressure ulcers. This means 
that Medicare criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 support surfaces are covered for 
enrollees with either multiple stage 2 ulcers or large stage 3 or 4 ulcers of the trunk or pelvis.    
We looked at the file and Medicare rules. There are no current pressure ulcers documented at the time of this 
request. Based on this information, we decided that Medicare rules for coverage of the Group 2 support surface 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 pressure-
reducing support surface.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic-based neuro-degenerative risk factor screening 
provided to the enrollee on October 19, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says screening genetic testing is not a covered benefit. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the denied testing evaluated the enrollee's symptoms of autonomic nervous system disorders but will not 
direct future management. Screening genetic testing is not a covered benefit. 
 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for genetic-based neuro-degenerative risk factor screening provided to the enrollee on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on May 11, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the laboratory results read no pathogenic or likely pathogenic variants detected. The review indicates that multiple outreach attempts were made to the provider's office to verify if the provider wrote an order for the 
enrollee to undergo cardiovascular genetic testing on or before DOS 05/11/2021. There are progress notes or 
office notes submitted for the date of service prior to genetic testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 11, 2021.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care 
at the current hospital and an LTACH would add no additional services. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic screening provided to the enrollee on 
July 14, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare covers lipid panel testing as cardiovascular screening once every 5 years and denies 
coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented 
cardiovascular disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare denies coverage for all cardiovascular genetic risk assessment panels. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride once every 5 years as 
cardiovascular screening. The review has determined that the services at issue in this case were not medically 
reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular genetic screening provided to the enrollee on July 14, 2021.
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 admission is medically necessary as it will allow 
the patient to regain her functional mobility after her car accident. The Plan denied your request. The Plan says 
IRF care is not medically necessary as the patient's needs can be met at a lower level of care. 
 
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 patient'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 surgical repair of hip fracture and tibial plateau fracture and was discharged home on 5522. There 
is ongoing weakness, but the patient's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stress transthoracic echocardiography (93351) doppler 
color flow (93325) and doppler echocardiography (93320). 
 
You asked the Plan to pre-approve a stress echocardiogram. You say that please see attached clinicals for the 
enrollee. The Plan denied your request. The Plan says the services requested do not meet medical necessity. 
 
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 a stress echocardiogram. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of negative stress echocardiograms in 2019 and 2020. The 
enrollees pre-test probability for an abnormal test is low and there is no documentation that the ECG shows an 
uninterpretable pattern. There is no evidence provided that would support the need for stress echocardiography. 
In summary, there is insufficient documentation to support the medical necessity for the requested stress 
echocardiography in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a stress echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stress transthoracic echocardiography (93351) doppler color flow (93325) and 
doppler echocardiography (93320).