Persius/hicric huggingface dataset:
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 have multiple acute medical needs that should 
be managed within a hospital setting and require a multidisciplinary team for 3 hours of therapy a day, it would 
not be safe to discharge home at this time. The Plan denied your request. The Plan says your records do not 
show that your rehabilitation needs are complex and do not need an intensive team for your care, services you 
need can be provided safely in other settings, 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 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 inpatient rehabilitation 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator supplies billed with code 
E0730 for October 23, 2022. 
 
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 billed supply is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the electrical nerve stimulator supplies 
billed with code E0730 for October 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI test (87801) provided October 12, 2022.  
You asked the Plan to pay for the Guidance UTI test. You say that the enrollee's physician ordered the 
Guidance UTI test due to the enrollee's history of chronic urinary tract symptoms that have failed to resolve 
with standard treatment. The Plan denied your request. The Plan says Guidance UTI is not a covered benefit 
because this test has not been approved by MolDX as meeting Medicares reasonable and necessary 
requirement. 
 
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 the Guidance UTI test have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guidance UTI test (87801) provided October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel (87481, 
87798) provided on August 22, 2022. 
 
You asked the Plan to pay for a urine PCR panel. You say that the PCR testing is considered unproven and not 
medically necessary. The Plan denied your request. The Plan says the claim was billed appropriately. 
 
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 a urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that signs and symptoms of a urinary tract infection (UTI) can be widely variable but include painful urination, flank or abdominal pain, and urinary frequency. Diagnosis of a UTI often involves evaluating 
a blend of patient clinical symptoms in combination with diagnostic testing. Laboratory tests include the 
urinalysis test, urine Gram stain, urine culture, and more recently the urine PCR test. Gold-standard laboratory 
tests vary in their ability to reliably detect a UTI, hence the approach to combine testing with patient signs and 
symptoms. Newer advancements to assess urine by multiplex PCR offer another diagnostic tool for laboratories 
to consider. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for a urine polymerase chain reaction (PCR) panel (87481, 87798) provided on August 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for September 18, 2022. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for procedure code 86077 billed for September 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical 
pump (E2402) and wound care set (A6550). 
 
You asked the Plan to pre-approve a NPWT pump and wound care set. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy pump (E2402) 
and supplies (A6550, A7000) are covered when certain 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 a NPWT pump and wound care set. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that continued use of the wound vacuum device at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records do not 
document wound improvement occurring in either surface area (length times width) or depth of the wound. 
 
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 NPWT pump and wound care set have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump (E2402) 
and wound care set (A6550).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 billed for July 27, 2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre- and post-operative services are included in the 
global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99490 was billed on the same day and related to 
minor surgical procedure 20552. Payment for code 99490 is included in the global surgical package for 20552. 
Therefore, we decided that the Plan does not have to pay for procedure code 99490 billed for July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Innovasis biologic allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the allograft is medically necessary. The Plan 
denied your request. The Plan says the allograft is 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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the 
Innovasis biologic allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to establish safety and efficacy. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Innovasis biologic allograft (20930), in this case, is 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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Innovasis biologic allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81315 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 30, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 
81315 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), two surgical extractions (D7210 x2), and panoramic x-ray (D0330) provided on October 21, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay more for the dental services. You say that the cost should be covered by the Plan. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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.

You have been asked to pay a 55% coinsurance for each surgical extraction, plus the difference between the OON provider's charges and the Plan's payment. 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 pay more for the comprehensive oral evaluation (D0150), two surgical extractions (D7210 x2), and panoramic x-ray (D0330) provided on October 21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the warranty (A9270), provided on July 7, 2022. 
 
You asked the Plan to pay for the warranty. You say that the service should be covered. The Plan denied your 
request. The Plan says that this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any information to support that the warranty charge 
cannot be covered. Therefore, we decided that the Plan has to pay for the warranty (A9270), provided on July 
7, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on October 21, 2022. 
 
You asked the Plan to pay for a swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract  
x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray) which is an excluded place of service per the Medicare LCD coverage criteria. 
Based on this information, we decided that Medicare rules for coverage of a swallowing function x-ray  
(CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided 
that the Plan does not have to pay for a swallowing function x-ray (CPT 74230), and an upper gastrointestinal 
tract x-ray (CPT 74240) provided on October 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Infliximab. 
 
You asked the Plan to pre-approve Infliximab. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Infliximab 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 Infliximab. Our reviewer says that the 
services are medically necessary. Our physician reviewer found subsequent treatments in this case meet 
coverage criteria, as there has been a reduction in signs and symptoms. No contraindications are identified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infliximab have been met. Therefore, we decided that the Plan has to pre-
approve Infliximab.  
 
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 procedure code 99211 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 99211. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99211 is bundled into payment for code 96372. 
 
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 99211 
is a column II code to column I code 96372. 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 procedure code 99211 billed for date of service October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic (D6740 x1), and 
pontic - porcelain/ceramic (D6245 x1). 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered because 
you have not used any dental crown services this year. The Plan denied your request. The Plan says because of 
frequency limitations, the additional one retainer crown - porcelain/ceramic (D6740) and one pontic - 
porcelain/ceramic (D6245) are denied. 
 
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, certain limitations apply. The record 
shows your benefit for the retainer crown - porcelain/ceramic, and pontic - porcelain/ceramic was exhausted on 
the reprocessed claim. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - 
porcelain/ceramic (D6740 x1), and pontic - porcelain/ceramic (D6245 x1).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 26, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were told you would only have a $20 
copayment. The Plan denied your request. The Plan says that the only chiropractic service Medicare covers is 
spinal manipulation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal scaling and root planing - one 
to three teeth per quadrant, upper right (D4342 x1), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, (D7210), resin-based composite - two surfaces, posterior (D2392), and resin-based 
composite - two surfaces, anterior (D2331) provided on October 8, 2022, and November 8, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services represented by codes D4342 x1, D7210, 
D2392, and D2331. You say that you have had to pay over $700 for dental cleanings and fillings. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 70% 
coinsurance for periodontal scaling and planning, and a 50% coinsurance for resin-based composite - two 
surfaces, posterior, and resin-based composite - two surfaces, anterior provided in-network. 
 
You have been asked to pay a 70% coinsurance for the periodontal scaling and planning (D4342 x1), and  a 
50% coinsurance for the extraction (D7210), resin-based composite - (D2392), and resin-based composite - two 
anterior (D2331). Periodontal scaling and root planing falls within the major dental services (endodontics, 
periodontics, and oral surgery) benefit category. Extraction, erupted tooth, and resin-based composite - two 
surfaces, posterior, and resin-based composite - two surfaces, anterior falls with the basic dental services 
(minor restorative) 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 coinsurance for periodontal scaling and root planing - one to three teeth per 
quadrant, upper right (D4342 x1), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, (D7210), resin-based composite - two surfaces, posterior (D2392), and resin-based composite - two 
surfaces, anterior (D2331) provided on October 8, 2022, and November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of an implant body (D6010) provided 
on February 1, 2022. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your dental 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 
surgical placement of an implant body (D6010) provided on February 1, 2022.