Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The enrollee does not require services that she is not currently receiving but that would be available at the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines require a trial of regular, daily, multiple-hour home usage of the basic device.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not clearly document lymphedema extending onto the chest, trunk or abdomen on any physical examination of the enrollee. All of the records just report right lower extremity lymphedema on exam. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 11, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on May 27, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was billed correctly. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that CPT code 81479 is not supported in the record. Specifically, this claim was billed with the 
laboratory place of service code while the records indicate that the member's face-to-face service was rendered 
in an office setting. Based on this information, we decided that Medicare rules for coverage of the Guardant360 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing 
(81479) provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says that information does not indicate that the member has tried and failed the preferred step 
therapy drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary. The Plan requires a trial of Retacrit or Procrit before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no 
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Aranesp. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on October 1, 2021.
You asked the Plan to pay for the testing services. You say that the specimens received are from providers who
have performed biopsies. The Plan denied your request. The Plan says the code remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. If an independent lab bills for services, the place where the sample was
taken is reported as the place of service. The claim lists a place of service as an independent laboratory. The
records do not show that the specimen was obtained at an independent laboratory. Based on this information,
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided
that the Plan does not have to pay for the lab testing services provided on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 30, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on the LTACH criteria. The Plan 
states the enrollee is receiving the care they need in the hospital where they are now and there is no need to 
transfer to the LTACH at this time. The Plan states the enrollee can stay in the hospital until they are safe for 
transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but still requires short-term acute care services 
that can be safely administered at the current facility until stable for a lower level of care. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 this immuno-compromised enrollee will be in 
jeopardy if discharged to a sub-acute rehabilitation due to infection rates and quality of care versus inpatient 
acute rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary based on 
IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for 
example: a skilled nursing facility, home with home health services, or home with outpatient therapy if 
appropriate. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical conditions are stable on outpatient medications with no 
issues that require a physicians evaluation three (3) or more times per week. The enrollee does require 
physical therapy and occupational therapy services but based on the medical records provided the enrollee does 
not require an intensive inpatient rehabilitation therapy program. The medical records provided there is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF due to poor endurance and weakness. Care at the skilled nursing facility level 
appears to be appropriate in this case. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 17, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 10, 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 81339, 81450, 81219, and 81270 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 81339 is MPL (MPL proto-oncogene, thrombopoietin
receptor) (e.g., myeloproliferative disorder) gene analysis; sequence analysis, exon 10. The definition of code
81450 is Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis,
and RNA analysis when performed, 5-50 genes. The definition of code 81219 is CALR (calreticulin) (e.g.,
myeloproliferative disorders), gene analysis, common variants in exon 9. The definition of code 81270 is JAK2
(Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant.
We find that CPT codes 81339, 81450, 81219, and 81270 are not supported in the medical record. Specifically,
there are no lab results for the billed services for the date of service at issue. 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 laboratory services rendered on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for each 
quadrant. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scalings and root planings (D4341) for each quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) and bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve the endosteal implant and bone graft. The Plan denied your request. The 
Plan says these services are not covered under the enrollee's benefit 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 
surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement 
(D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 7. 
 
You asked the Plan to pre-approve a crown for tooth 7. You say that your crown broke and you need a new 
one. 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 a crown for 
tooth 7 once every 60 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a crown for tooth 7 
on October 23, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of a 
crown for tooth 7 has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a crown 
- porcelain/ceramic (D2740) for tooth 7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneers (porcelain laminate) (D2962) for your 
front teeth. 
 
You asked the Plan to pre-approve veneers. You say that these services are necessary, and you do not 
understand why they are not covered. The Plan denied your request. The Plan says these services are not 
covered by your 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, 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 
labial veneers (porcelain laminate) (D2962) for your front teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and re-
cement or re-bond crown (D2920) provided on September 29, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and re-cement or re-bond crown. 
You say that you are on a fixed budget and on Medicare dental with no other extra dental insurance or funds to 
cover this charge. You also say that you would like some assistance regarding this matter. The Plan denied 
your request. The Plan says these services are not covered expenses under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and re-cement or re-bond crown (D2920) provided on 
September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), drugs or 
medicaments dispensed in the office for home use (D9630), and four resin-based composites (D2330 x4) 
provided from October 8, 2021 to October 15, 2021. 
 
You asked the Plan to pay for the gingival irrigations, drugs or medicaments, and resin-based composites. You 
say that you would like to appeal the denial of coverage for these services. The Plan denied your request. The 
Plan says gingival irrigations and drugs or medicaments are not covered expenses under your dental plan. The 
Plan also says that your benefit for resin-based composites has been satisfied and the frequency limitation has 
been exceeded. 
 
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, gingival irrigation (D4921) and drugs 
or medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. 
The contract says that restorations (fillings) are limited to one procedure code per calendar year. The record 
shows that between October 11, 2021, and October 13, 2021 you received five resin-based composites (D2330 
x5), one of which was covered by the Plan, and your restorations benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), drugs or medicaments 
dispensed in the office for home use (D9630), and four resin-based composites (D2330 x4) provided from 
October 8, 2021 to October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 23, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe there may 
be a misunderstanding regarding this claim. You also say that the provider had to verify the extent of the 
damage and the appropriate anesthesia to be used during this appointment. The Plan denied your request. The 
Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on September 14, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on September 23, 2021.