Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show physical exam results that show a reason for why this study is 
needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is a physical exam 
dated 1/21/22 at which time a normal neurological exam was documented. The formal report of the x-ray 
reference in the appeal letter is not included. The enrollee has no red flags to mandate immediate MRI without 
a trial of conservative management including physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: 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 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 were admitted for pneumonia, congestive heart failure, and myocardial infarction. Medical problems are 
stable. 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 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 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation (92012) deluxe frames (V2020) bifocal lenses (V2200) tint, photochromatic 
(V2744) anti-reflective coating (V2750) progressive lens (V2781) lens, index 1.54-1.65 p/1.60-1.79g (V2782) 
provided November 6, 2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that you should not be responsible 
for the charges on the basis that the glasses received hurt due to your nose bridge sensitivity. The Plan denied 
your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of 
Coverage. 
 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 $10 
copayment for routine eye exam every year. If you purchase glasses (eyeglass frames and lenses) in the 
designated collection, frames and lenses are covered in full. If you purchase glasses outside of the designated 
collection, but at a participating provider you are covered up to $150.  
 
You have been asked to pay $467 ($10 + $457) for the vision services. The vision services fall within the 
Vision 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 ophthalmological services: 
medical examination and evaluation (92012) deluxe frames (V2020) bifocal lenses (V2200) tint, 
photochromatic (V2744) anti-reflective coating (V2750) progressive lens (V2781) lens, index 1.54-1.65 p/1.60-
1.79g (V2782) provided November 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dermatology office visit provided on October 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that the records support that the place of service (POS) 
code is correct. The Plan denied your request. The Plan says that the POS code is not valid as the enrollee was 
seen in a facility on the same date. 
 
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 a valid denial rationale in this case. The Plan indicates 
that the POS code is incorrect because the services were provided in a facility setting. However, the 
documentation provided shows that the enrollee was seen on the same date of service for a visit at a nearby 
rural health center (RHC). There is no evidence that the RHC is affiliated with the dermatology practice, and 
the claims show that the services occurred in two different locations. There is no reason that the dermatology 
practice would be required to report a different POS code if the enrollee was seen in an RHC on the same date. 
We find that the denial of payment is not substantiated in the case. Therefore, we decided that the Plan has to 
pay for the dermatology office visit provided on October 11, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you had a stroke and have declined in function 
but have been getting better with physical therapy.  You said that you live alone and you are unable to care for 
yourself. The Plan denied your request. The Plan says you are not yet ready for discharge from the hospital and 
therefore can receive needed care in the current hospital facility. Transfer to a SNF is not medically necessary 
at this time.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing 
or skilled therapy needs.  The doctor says that you do not require this care on a daily basis in an inpatient 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or 
hospice settings, each 15 minutes (G0156). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided records do not document any acute or unstable medical conditions which would necessitate any home 
health aide visits beyond what have already been approved. The reviewer found that there are no medical notes 
from the enrollees treating physician are provided documenting a need for home health aide services.  Based on the provided records the enrollee's needs appear to be custodial. Therefore, the reviewer found that 
the requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve services of home health/hospice aide in home health or hospice settings, each 15 
minutes (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system. 
 
You asked the Plan to pre-approve a life alert system. You say that a life alert system is medically necessary. 
The Plan denied your request. The Plan says life alert systems are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  This equipment is precautionary and does not serve a purpose that is primarily medical in 
nature. Therefore, we decided that the Plan does not have to pre-approve a life alert system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 23 tooth extractions. 
 
You asked the Plan to pre-approve 23 tooth extractions. You say that these extractions are medical rather than 
dental. The Plan denied your request. The Plan says these extractions are not covered. 
 
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, extractions are only covered twice per 
calendar year. The record shows that 25 extractions were requested, and the Plan approved 2. Therefore, we 
decided that the Plan does not have to pre-approve 23 tooth extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had several issues with your previous 
dentist. You say that you found a new one closer to your house. You say that you were advised you needed 
$16,000 worth of work done on your teeth. You also say that you feel you were taken advantage of. The Plan 
denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan 
says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits 
have 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 the services are listed as covered, 
the frequency limits of once every 3 plan years has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation and complete series x-ray that you received on October 20, 2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series 
x-ray (D0210) provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided January 3, 2022. 
 
You asked the Plan to pay for the dental cleaning. You say that you had a salivary gland cancer and due to 
surgery and radiation treatment, you need prophylaxis every 4 months. The Plan denied your request. The Plan 
says you have exceeded the frequency limit for this service. 
 
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 the dental 
cleaning once every 6 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you previously had a 
dental cleaning covered on August 23, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the dental cleaning has been exceeded. Therefore, we decided that the Plan does not have 
to pay for the prophylaxis - adult (D1110) provided January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure (G0452-59) and 
morphometric analysis (88377-59) provided on August 31, 2021. 
 
You asked the Plan to pay for a molecular pathology procedure and morphometric analysis. You say that these 
services were billed correctly. The Plan denied your request. The Plan says these were not separate services. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 molecular pathology procedure and 
morphometric analysis. Our reviewer says that these codes are not supported. Our physician reviewer found 
testing the same gene or genetic region by a different metrology is not allowable. 
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 molecular pathology procedure and morphometric analysis have not been met. 
Therefore, we decided that the Plan does not have to pay for a molecular pathology procedure (G0452-59) and 
morphometric analysis (88377-59) provided on August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on September 21, 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 procedure codes 95937, 95813, 95907, and 95886 are 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 code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95813 is electroencephalogram 
(EEG) extended monitoring; 61-119 minutes. The definition of code 95907 is nerve conduction studies; 1-2 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal 
areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or 
more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in 
addition to code for primary procedure). 
 
We find that CPT codes 95937, 95813, 95907, and 95886 are not supported in the medical record. Specifically, 
there is no documentation of neuromuscular junction testing for each nerve by any one method to support code 
95937. There is no documentation of an EEG extended monitoring for 61-119 minutes to support code 95813. 
There is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation 
of a complete needle electromyography to support code 95886. 
 
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 testing services rendered on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental item. You say that you paid for the upgraded dental coverage. You say 
that you feel at least part of this should be covered. You also say that the night guard is medically necessary to 
help prevent headaches from grinding your teeth. The Plan denied your request. The Plan says occlusal guard is 
not a covered service. 
 
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 occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard 
(D9944) provided on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from May 27, 2021, to May 
31, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. 
The CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes. 
We looked at the file and the rules. We find that CPT codes are not supported in the medical record. The 
records do not indicate the amount of time was spent with the enrollee. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital services provided from May 27, 2021, to May 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cell-based bone marrow allograft material. 
 
You asked the Plan to pre-approve cell-based bone marrow allograft material. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says this procedure is 
experimental/investigational. 
 
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 cell-based bone marrow allograft 
material. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found cell-based bone marrow allograft material and also bone 
marrow aspirate remain experimental. More research is needed to show safety and efficacy before coverage can 
be approved.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cell-based bone marrow allograft material have not been met. Therefore, we 
decided that the Plan does not have to pre-approve cell-based bone marrow allograft material.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied 
your request. The Plan says limited oral evaluations are not covered when performed on the same day as 
routine services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluations are listed 
as covered, they are not eligible for coverage when performed on the same day as routine services. The record 
shows that the limited oral evaluation was performed on the same date as an extraction. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 21, 2021.