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

 
We decided that the Plan does not have to pre-approve the 5,10-methyenetetrahydrofolate reductase (MTHFR) 
testing requested under code 81291. 
 
You asked the Plan to pre-approve the MTHFR gene testing. You say that this testing is needed to determine 
the ideal treatment medication for the enrollee's mental health conditions. The Plan denied your request. The 
Plan says the Genesight testing under code 81479 was approved. However, there is no evidence that MTHFR 
testing is necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is not considered medically 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MTHFR gene testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the 5,10-methyenetetrahydrofolate reductase (MTHFR) testing requested under code 81291.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you need dentures. The Plan denied your 
request. The Plan says dentures are not listed as 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, the requested complete dentures are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
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 February 21, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you cannot have dental 
issues because it directly effects your heart problems. You also say that you always had this covered under your 
other Medicare without issue. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 
benefits and provider eligibility. 
 
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 pay for the 
problem focused limited oral evaluation (D0140) provided on February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc knee injections. 
 
You asked the Plan to pre-approve the Orthovisc injections. You say that this is a medically necessary 
treatment. The Plan denied your request. The Plan says there is no documentation of the results of the 
documented steroid injection, nor any documentation of other measures attempted. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc injections. Our reviewer 
says that the records do not support the medical necessity of the requested drug. Our physician reviewer found 
the provided records do not document failure of the corticosteroid injection or other conservative 
treatments. Without this documentation, the requested treatment is not supported. 
 
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 Orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc knee injections.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from this level of care. The 
Plan denied your request. The Plan says that the services the enrollee needs can be provided safely in other 
settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for non-surgical 
management of right knee and right wrist fracture. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ophthalmoscopy services provided on  
February 23, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmoscopy services. The Plan denied your request. 
The Plan says that the claim processed 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). The enrollees contract with the Plan says that enrollees must pay a 
$0 copayment for the ophthalmoscopy services. 
 
The Plan says the enrollee must pay a $14.16 copayment for ophthalmoscopy services. Based on the Plan 
contract, however, the enrollee cannot be asked to pay more than a $0 copayment for the ophthalmoscopy 
services. Therefore, we decided that the Plan has to waive the copayment for ophthalmoscopy services 
provided on February 23, 2022.  
 
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 duplex scan of lower extremity arteries or arterial 
bypass grafts; complete bilateral study (93925). 
 
You asked the Plan to pre-approve the duplex scan. You say that this scan is medically necessary because the 
enrollee has abnormal ankle-brachial index (ABIs) and an abnormal result of cardiovascular function study. 
The Plan denied your request. The Plan says the criteria for coverage of this scan are not met in this case. 
 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 duplex scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provider states in their appeal letter that the enrollee has abnormal ABIs, which could 
be because of peripheral vascular disease. The review has determined that there are not significant signs and/or 
symptoms indicate a high likelihood of limb ischemia, and the enrollee is not a candidate for invasive 
therapeutic procedures under any of the circumstances as listed in the LCD. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 
(93925).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on August 24, 
2021. 
 
You asked the Plan to pay for physical therapy services. You say that you have provided medical records to 
support the services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the record shows that the services of a PTA have been 
billed as services incident to a physician/NPP's service. Based on this information, we decided that Medicare 
rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (97110) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider. 
 
You asked the Plan to pay for dental services. You say that you need to use this specific doctor. The Plan 
denied your request. The Plan says dental services must be provided by a participating provider. 
 
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 dental 
services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. The requested provider is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that CPAP therapy 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a recent 
in-person evaluation by your treating provider that shows you have continued to use and benefit from the 
CPAP device. The criteria for coverage are not met and the CPAP therapy is therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuous positive airway pressure (CPAP) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant/abutment supported fixed denture for the upper 
arch (D6114). 
 
You asked the Plan to pre-approve the fixed denture. You say that this service is necessary. The Plan denied 
your request. The Plan says this item is not covered by the enrollee's 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 
implant/abutment supported fixed denture for the upper arch (D6114).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apicoectomy-premolar (D3421) and a retrograde filling 
(D3430), provided by a participating provider. 
 
You asked the Plan to pre-approve apicoectomy-premolar and a retrograde filling. You say that you would like 
the Plan to approve these services. The Plan denied your request. The Plan says the requested dental services 
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, 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 
apicoectomy-premolar (D3421) and a retrograde filling (D3430), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antireflective coating (V2750), provided on January 4, 
2022. 
 You asked the Plan to pay for the antireflective coating. You say that this item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the antireflective coating (V2750), provided on January 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve outpatient mental health services provided on December 15, 2021. 
 
You asked the Plan to pre-approve the outpatient mental health services. You say that the provider of service is 
a LCSW and is Medicare-eligible as of January 31, 2019. The Plan denied your request. The Plan says that the 
provider of service is not eligible. 
 
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. Specifically, the Plan's sole rationale for denial is that the provider of service is 
not an eligible provider.  However, you have provided definitive proof of this provider's Medicare eligibility in 
the form of a letter from the Centers for Medicare and Medicaid Services granting this LCSW participation 
status as of January 31, 2019.  The Plan has made no efforts to refute this proof.  The burden is on the Plan to 
prove that its denial is appropriate, and they have failed to do so in this case. Therefore, we decided that the 
Plan has to pre-approve outpatient mental health services provided on December 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear provided on December 1, 2021. 
 
You asked the Plan to pay for the routine eyewearr. You say that the item should be covered. The Plan denied 
your request. The Plan says the item was not obtained in-network.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained within the Plan's network. 
 
We looked at the file and the Plan's rules. Specifically, the eyewear was not obtained through the Plan's 
network. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine eyewear provided on 
December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 2, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were unaware of limits for this 
service. 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 
periodontal maintenance three times per plan year. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal 
maintenance was previously covered on January 28, 2021, April 28, 2021, and July 20, 2021. Based on this 
information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been 
exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for medical services provided to the enrollee on December 14, 2021. 
 
You asked the Plan to pay for medical services provided to the enrollee. You say that this service should be 
covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. The 
Plan says that when a mid-level provider renders a service, they must bill under the supervising physician for 
coverage. 
 
The Plan must follow Medicare rules. Medicare requires providers to submit claims appropriately. In this case 
this claim cannot be paid as billed since it is not being billed under the supervising physician.  Medicare rules 
for coverage of this claim are not met. Therefore, we decided that the Plan does not have to pay for medical 
services provided to the enrollee on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper dentures. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual 
policy. 
 
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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve upper dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve a complete upper and lower denture. You say that you would like the 
dentures covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
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 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the humerus repair (24430) provided on January 27, 2021. 
 
You asked the Plan to pay for the humerus repair (24430). You say that the claim has been billed correctly and 
the documents should be reviewed as 24430 is a payable code. The Plan denied your request. The Plan says 
procedure code 24430 is not supported by the medical records submitted. 
 
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 24430 is repair of nonunion or malunion, humerus; 
without graft (eg, compression technique). 
 
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 humerus repair (24430). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not document a nonunion or malunion repair per the NCCI Policy Manual. The operative 
report describes an open reduction internal fixation of left intra-articular distal humerus fracture. Therefore, 
CPT code 24430 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 humerus repair (24430) have not been met. Therefore, we decided that the 
Plan does not have to pay for the humerus repair (24430) provided on January 27, 2021.