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

 
We decided that the Plan does not have to pre-approve a core buildup for teeth #29 and #31 (D2950, a retainer 
crown for teeth #29 and #31 (D6740) and fixed prosthodontics, pontic for tooth #30 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you need the molar replaced, as it is the 
main tooth to eat with. The Plan denied your request. The Plan says the items are either not a covered benefit or 
not medically necessary. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the 
provided records show tooth #29 with an existing crown that does not appear to have any defects, and tooth 
#31 has an existing two surface restoration that does not appear to be defective.  A bridge is a reasonable but 
not necessary, and it would require cutting off an otherwise serviceable crown. An implant is a better 
suggestion however the member does not wish to pursue an implant. A removable appliance is another option. 
The plan states that "The placement of a fixed prosthetic appliance will only be considered for those 
exceptional cases where there is a documented physical or neurological disorder that would preclude placement 
of a removable prosthesis." In this instance, there is no indication of any physical or neurological disorders that 
would prevent the use of a removable appliance. Given the Plan limitation, the criteria for a fixed bridge has 
not been met. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a core buildup for teeth #29 and #31 (D2950, a retainer crown for teeth #29 and #31 
(D6740) and fixed prosthodontics, pontic for tooth #30 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that genicular nerve blocks for the treatment of chronic knee pain are 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Cooled 
radiofrequency ablation (RFA) does not meet criteria for neurolysis of any nerve. Genicular RFA is considered 
experimental/ investigational and clinical trials are still being conducted to determine its role in the 
management of post total knee arthroplasty pain. 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 a genicular nerve block (64624) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220), limited oral exam (D0140) and 
periodontal scaling and root planing (D4342) provided from November 19, 2021, to December 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told this provider does not work with 
Medicare, but these services were medically necessary, and you feel these services should be covered by your medical insurance. The Plan denied your request. The Plan says the requested services are dental in nature. 
Services are not covered when they are received from a provider who does not accept Medicare payment. 
 
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 requires dental 
services to be performed by a licensed dental provider who accepts Medicare patients in the United States. You 
will not receive reimbursement if you use a provider that has opted out of Medicare.  
 
We looked at the file and the Plan's rules. The provider in this case does not accept Medicare payment and has 
opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the dental 
services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray 
(D0220), limited oral exam (D0140) and periodontal scaling and root planing (D4342) provided from 
November 19, 2021, to December 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
rides to get to and from your doctor's appointments. You have more than 2 visits per month for various medical 
issues, including surgery. The Plan denied your request. The Plan says additional trips would exceed your 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical information just shows pain without any signs of 
radiculopathy on examination. 
 
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. You have not had 
recent a MRI or conservative therapy. There is no physical exam findings of radiculopathy. Our physician 
reviewer found that your 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 an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid-19 testing (U0004) provided October 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that healthcare providers were faced with many 
challenges including obtaining the appropriate information to bill your claims for services rendered. The Plan 
denied your request. The Plan says the claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until October 21, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the Covid-19 testing (U0004) provided October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (G0483) provided November 11, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration and 
payment in full for the toxicology drug screen performed for the enrollee. The Plan denied your request. The 
Plan says the condition of the enrollee did not meet the Medicare rules for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not document the results of a screen were presumptively positive or 
the results of a screen were negative, and this negative finding was inconsistent with the enrollee's medical 
history or there was no presumptive test available, locally and/or commercially, as may be the case for certain 
synthetic or semi-synthetic opioids. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive urine drug testing (G0483) provided November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided to the 
enrollee on May 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 the review has determined that the 
records did not support that 31+ minutes of discharge day management were rendered in this case. The 
discharge document submitted indicates that 25 minutes were spent on patient care time; therefore, the billed 
service cannot be verified.  
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 hospital discharge day management services provided to the enrollee on May 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy office visit (90837) provided October 13, 
2021. 
 You asked the Plan to pay for the office visit. You say that you are enrolled as a clinical social worker effective 
1/13/2019 to current. The Plan denied your request. The Plan says the provider is credentialed as a mental 
health counselor. A mental health counselor is not an eligible provider under Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy office visit (90837) 
provided October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full thickness graft provided to the enrollee on June 23, 
2021. 
 
You asked the Plan to pay for the graft. You say that this should be paid for. The Plan denied your request. The 
Plan says the provider does not detail the size of the total wound defect surface area requiring full thickness 
graft closure. 
 
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 15240 is "Full thickness graft, free, including direct 
closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or 
less." 
 
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 graft. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the operative report does not include 
documentation to support a 20 sq cm or less full thickness graft, and therefore cannot be verified. 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 graft have not been met. Therefore, we decided that the Plan does not have 
to pay for a full thickness graft provided to the enrollee on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
rendered on September 24, 2021 and December 22, 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 the services are not separately payable. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. 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 additional 
supplies, materials, and clinical staff time rendered on September 24, 2021 and December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
9, 2021, to July 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was adjusted.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found even though sepsis is documented, supporting medical record documentation 
was not found within the record. DRG 193: SIMPLE PNEUMONIA AND PLEURISY WITH MCC is the 
more appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 9, 2021, to July 13, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve Proton Beam Radiation Therapy.

You asked the Plan to pre-approve Proton Beam Radiation Therapy. You say that you believe proton therapy is medically necessary for the treatment of the enrollee's cancer. The Plan denied your request. The Plan says that there is no current research showing that the enrollee's type of cancer responds better to Proton Beam Radiation therapy than IMRT.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Proton Beam Radiation Therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the National Comprehensive Cancer Network Panel believes no clear evidence supports a benefit or decrement to proton therapy over Intensity Modulated Radiation Therapy (IMRT) for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to x-ray-based regimens at clinics with appropriate technology, physics, and clinical expertise. The selected location appears to have this expertise. The service is reasonable and 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 Proton Beam Radiation Therapy have been met. Therefore, we decided that the Plan has to pre-approve Proton Beam Radiation Therapy.

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 pre-approve a computed tomography (CT) scan of the abdomen 
(74150). 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the requested imaging service is 
medically reasonable and necessary. The Plan denied your request. The Plan says there is no medical need for 
the requested imaging as there is no evidence the requested study would improve the enrollee's outcome for 
their condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen. Our 
reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer 
found given the cancer diagnosis, and recent standard of care guidelines recommending abdominal imaging in 
patients with incidental adrenal lesions in the setting of known cancer, an abdominal CT scan could be 
considered medically reasonable and necessary.  However, the adrenal mass appears to have been present in the 
past and followed in the past. Without knowledge of the size of the lesion, how long it has been present, or any 
changes over time, current guidelines would not recommend serial imaging at this time. 
 
 
 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 CT scan of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen (74150).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 21, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your husband was suffering from a 
psychotic episode. You say that he instructed the doorman to call 911 for you while you were sleeping. You 
also say that you would like the decision to be reversed. The Plan denied your request. The Plan says since 
there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 21, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 physical function is at or near your 
baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.