Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the ConfirmMDx testing (81551) provided on September 9, 2021. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that there was no documented result of 
prior prostate biopsy. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx 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 pay for the ConfirmMDx testing. Our reviewer says 
that the member meets the LCD criteria for coverage of the ConfirmMDx testing. Our physician reviewer 
found the records show that the member had a prostate biopsy that was benign. 
 
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 ConfirmMDx testing have been met. Therefore, we decided that the Plan 
has to pay for the ConfirmMDx testing (81551) provided on September 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits (G0299 x4). 
You asked the Plan to pre-approve 4 additional skilled nursing visits. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 4 additional skilled nursing visits. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records do not document any acute or unstable medical conditions or changes 
in medication or treatment which would necessitate any further skilled nursing visits beyond what have already 
been 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 4 additional skilled nursing visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 4 additional home health skilled nursing visits (G0299 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the orthopedic office visit and the Kenalog 
injection you received on December 22, 2020. 
 
You asked the Plan to waive the cost sharing for the orthopedic office visit and the Kenalog injection. You say 
that this claim should be paid because that is why you have insurance. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $40 
copayment for visits with a specialist and 20% coinsurance for Medicare Part B drugs.   
You have been asked to pay a $40 copayment for the orthopedic office visit and 20% coinsurance for the 
Kenalog injection. The orthopedic office falls within the visits with a specialist benefit category and the 
Kenalog injection is a Medicare Part B drug. 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 cost sharing for the 
orthopedic office visit and the Kenalog injection you received on December 22, 2020.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing 
or skilled therapy services, or a combination of these services, on a daily basis in a SNF. As a practical matter, 
you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 18 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 18 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an additional 18 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
your condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 18 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 18 physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 300 units of Botox (J0585), no less than every 90 days. 
 
You asked the Plan to pre-approve the Botox. The Plan denied your request. The Plan says the Food and Drug 
Administration (FDA) recommends 100 units of Botox and is the maximum recommended dose for her 
medical condition. The Plan also says that the request of the 300 units of Botox injection exceeds the FDA 
maximum recommendation. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that 300 
units of Botox (J0585), no less than every 90 days is not medically reasonable and necessary for the enrollee. 
Our physician reviewer found the Food and Drug Administration limits the dose of the requested drug to 100 
units. Our reviewer found that the record provided does not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested service. Our physician reviewer also found that the elements of 
the coverage criteria are not satisfied, and the requested service is not recommended. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 300 units of Botox (J0585), no less than every 90 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you are requesting coverage for the 
occlusal guard in order to avoid further tooth damages and to cure the jaw pain you are experiencing. The Plan 
denied your request. The Plan says this service is not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9945).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on October 8, 2021.
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 and 70496.
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 70450 is a column II code to column I code 70496. 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 the computed tomography (CT) of the head or brain (70450) provided on October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on September 8, 2021.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that the Plan should pay this claim. The Plan denied your request. The Plan says payments for self-administered drugs provided during a facility stay must be submitted to your Medicare Part D carrier.
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 pay for self-administered drugs provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D1206 and D4342) provided on September 10, 2021. 
 
You asked the Plan to pay for dental codes D1206 and D4342. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says dental codes D1206 and D4342 are not 
covered under the Plan's supplemental dental benefit. 
 
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, dental codes D1206 and D4342 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D1206 and D4342) provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear (85060) provided on October 4, 2021.
You asked the Plan to pay for the blood smear. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been billed with an inappropriate place of service code.
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 code 85060 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 85060 has a professional/technical component indicator of 8. This means that no payment is recognized for CPT code 85060 furnished to hospital outpatients or non-hospital patients. This claim was billed with Place of Service code 22 for on-campus outpatient hospital. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear (85060) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services provided on June 16, 2021, 
and July 28, 2021. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says dental codes D2950 and D2740 were 
denied for maxed benefit reached and code D2954 was denied as it is not a covered benefit under the 
supplemental dental benefit. 
 
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. 
We looked at the file, the Plan's contract, and Medicare rules. The Plan's contract shows that dental code 
D2950 is covered only once per year. The file shows dental code D2950 was reported 3 times and the Plan paid 
for one line per the contract with the Plan. The Plan's contract shows that dental code D2740 is covered 3 times 
per year. The file shows that you previously were provided services submitted with dental D2740 3 times on 
July 29, 2021, which the Plan paid for. Lastly, dental code D2954 denied as this code is not covered under your 
supplemental dental benefit. Therefore, we decided that the Plan does not have to pay additionally for the 
dental services provided on June 16, 2021, and July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #4.
You asked the Plan to pre-approve the crown. You say that there is a crack and you do not want it to get worse. The Plan denied your request. The Plan says there is no clinical evidence to support medical necessity.
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. The Plan covers the 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 the crown. Our reviewer says that the
documentation provided does not meet the criteria for coverage for a crown (D2740) for tooth #4. Our
physician reviewer found tooth #4 has an occlusal restoration. Our reviewer found that there was no narrative
indicating you have any symptoms. Our physician reviewer also found that the tooth does not show significant
coronal breakdown due to caries or fracture to warrant a crown restoration.
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 the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2740) for tooth #4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64447) provided on June 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 64447 is a column II code to column I code 01402. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (64447) provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0431, D9630, D9975, D4921, D4381, 
and D4999) provided on November 8, 2021. 
 
You asked the Plan to pay for dental codes D0431, D9630, D9975, D4921, D4381, and D4999. You say that 
you would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental codes 
D0431, D9630, D9975, D4921, D4381, and D4999 are not covered under the Plan's supplemental dental 
benefit. 
 
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, dental codes D0431, D9630, D9975, 
D4921, D4381, and D4999 are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the dental services (D0431, D9630, D9975, D4921, D4381, and D4999) provided on 
November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival flap procedure (D4241), bone replacement 
graft (D4263), and biologic materials to aid in soft and osseous tissue regeneration (D4265). 
 
You asked the Plan to pre-approve the gingival flap procedure, bone replacement graft, and biologic materials. 
You say that these services are necessary to maintain good dental health. You also say that you feel these 
procedures are important for you to avoid further health complications and more expenses. The Plan denied 
your request. The Plan says these services are not covered under your dental coverage plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
gingival flap procedure (D4241), bone replacement graft (D4263), and biologic materials to aid in soft and 
osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7210, D7140, D4212, D2393, and 
D2392) provided on May 22, 2020. 
 
You asked the Plan to pay for dental codes D7210, D7140, D4212, D2393, and D2392. You say that you would 
like the Plan to reconsider your request. The Plan denied your request. The Plan says dental codes D7210, 
D7140, D4212, D2393, and D2392 are not covered under the Plan's supplemental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D7210, D7140, D4212, 
D2393, and D2392 are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the dental services (D7210, D7140, D4212, D2393, and D2392) provided on May 22, 2020.