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

 
We decided that the Plan does not have to pay for a filling (D2393), a crown (D2740), and core build up 
(D2950) provided on April 5, 2021, two fillings (D2332, D2335) provided on April 15, 2021, and two fillings 
(D2335) provided on April 26, 2021. 
 You asked the Plan to pay for fillings, a crown, and core build up. You say that you found out in April 2022 
that you had dental coverage for services in 2021. The Plan denied your request. The Plan says that a crown 
(D2740) and core build up (D2950) are not covered by your dental benefits. The Plan also says that your 
benefit for fillings has 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a crown and core build up are not 
among those covered under this benefit. The record shows your benefit for fillings has been exhausted on date 
of service April 5, 2021. Therefore, we decided that the Plan does not have to pay for a filling (D2393), a 
crown (D2740), and core build up (D2950) provided on April 5, 2021, two fillings (D2332, D2335) provided 
on April 15, 2021, and two fillings (D2335) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve full mouth debridement (D4355). We also decided that the Plan 
does not have to pre-approve a crown on tooth #19 (D2750).  
 You asked the Plan to pre-approve a crown and debridement. You say that you want the procedures covered. 
The Plan denied your request. The Plan says that there is less than 50% bone support on tooth #19. The Plan 
also says that you had a regular cleaning or evaluation within the last 12 months. 
 
We decided that the Plan has to pre-approve full mouth debridement (D4355).  
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing you received a regular cleaning or evaluation with the last 12 
months. Therefore, we decided that the Plan has to pre-approve full mouth debridement (D4355).  
 
We also decided that the Plan does not have to pre-approve a crown on tooth #19 (D2750). 
 
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 a crown 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 a crown. Our reviewer says that the 
coverage criteria for a crown has not been met. Our physician reviewer found that a review of the 
documentation indicates that the distal root of tooth #19 has minimal bone support and there is lack of bone 
support in the bifurcation of the roots. The prognosis for the retention of this tooth is poor. 
 
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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #19 (D2750). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve an HFCWOD. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested item is not a covered benefit in the 
enrollees clinical situation.  
 
The Plan must follow Medicare rules. Medicare rules say that high-frequency chest-wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
 
  The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high-frequency chest-wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve an HFCWOD.
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 for inpatient rehabilitation for training, 
and you need this to regain maximum function. The Plan denied your request. The Plan says you do not meet 
the Medicare criteria for an 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer also found that 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the services the enrollee needs can safely be received at a different setting. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee appears unable to participate in the rigors of daily skilled 
therapy.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition.  The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (procedure codes 67728, 92134, 
92014) provided to the enrollee on March 24, 2022. 
 
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 service is included in another service provided at the same time and isn't allowed separately. 
 
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 67728: 
 
Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation 
 
CPT 92134: 
 
Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits 
 
CPT 92014: 
 
Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, 
unilateral or bilateral; retina 
 
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 that there is an edit with procedure 
codes 92014 and 67228. The medical documentation does not support the use or procedure code to be used 
within the global period of previous procedures with this provider or patient. 
 
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 ophthalmology services (procedure codes 67728, 92134, 92014) provided to the enrollee on 
March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 
March 7, 2022 billed with codes 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination coded G0402 and 
the hospital outpatient clinic visit coded G0463 provided on March 9, 2022. 
 
You asked the Plan to pay for the initial preventive physical examination and the hospital outpatient clinic visit. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are 
not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, these two 
codes were billed with the same revenue code on the same date of service. These services must be billed with 
condition code G0. The condition code G0 specifies that multiple medical visits occurred on the same day with 
the same revenue center, and that these visits were distinct and constituted independent visits. The documentation does not support that these services were billed with the correct condition code. Based on this 
information, we decided that Medicare rules for coverage of the initial preventive physical examination and the 
hospital outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the initial preventive physical examination coded G0402 and the hospital outpatient clinic visit coded G0463 
provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for those patients that do not receive adequate relief from traditional conservative methods and 
don't have instability to indicate fusion is the appropriate treatment. You say that the enrollee has tried and 
failed conservative treatment without relief. The Plan denied your request. The Plan says the requested 
treatment is considered investigational and experimental. The Plan says that it is unproven and 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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement, mitral valve, with cardiopulmonary bypass 
(33430), modified maize procedure (33254) and inpatient hospital admission for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member needs these services immediately. 
The Plan denied your request. The Plan says that records do not show that the enrollee has severe mitral 
regurgitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Echocardiography in 
February of 2022 assessed the mitral regurgitation as less than severe. As such, the documentation would not 
suggest that the mitral regurgitation is of sufficient severity to warrant valve replacement. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement, mitral valve, with cardiopulmonary bypass (33430), modified maize 
procedure (33254) and inpatient hospital admission for the enrollee.
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 need extensive rehabilitation and pulmonary 
therapy. You say that your life would be jeopardy if you were released home with home health care. The Plan 
denied your request. The Plan says the enrollee does not support the need for an intensive rehabilitation therapy 
program consisting of at least 3 hours of therapy per day at least 5 days per week. The Plan says that 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 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 respiratory failure and COPD exacerbation. Medical problems are stable. 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 medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 13, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says in 
order for a facility to receive reimbursement for a Medicare member, the facility must be enrolled to participate 
in the Medicare program. If the freestanding facility did receive temporary approval to enroll in Medicare, the 
facility will need to submit the CMS documentation to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an emergency department visit 
provided on January 13, 2022 have been met. The file does not show proof of temporary approval to enroll in 
Medicare. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided 
on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOneHeme (F1Heme) testing provided on 
November 30, 2021. 
 
You asked the Plan to pay for the F1Heme test (81455). You say that the testing procedures is proven 
medically necessary and is a covered benefit for comprehensive genomic profile testing for cancer. The Plan 
denied your request. The Plan says the testing is unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as 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 pay for genomic profiling test procedure (requested 
under code 81455). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there are many potential causes of 
thrombocytosis, including myeloproliferative neoplasms and other hematologic malignancies. However, the 
FoundationOne Heme testing in this case exceeded the enrollees need and was unlikely to impact clinical 
decision-making. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genomic profiling test procedure (requested under code 81455) have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOneHeme (F1Heme) testing 
provided on November 30, 2021.