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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that please review in regards to the denial 
for spinal surgery. The Plan denied your request. The Plan says the clinical value and effectiveness of bone 
marrow aspirate in the setting of spinal fusion surgery have not been demonstrated. Medical studies have not 
been proven that this procedure is helpful for treatment of the enrollee's problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bone marrow aspirate have not been met. 
 
 Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the determination of refractive state (92015) provided on December 17, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the determination of refractive state. You say that you were enrolled in the 
Optional Supplemental Benefits on this date of service. The Plan denied your request. The Plan says that this 
service was rendered by an OON provider. The Plan also says that this OON vision care service/material is not 
covered. 
 
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 a $40 allowance for a routine eye exam every year from an OON provider. 
 
We looked at the file and the Plan's rules. The record shows that on this same date of service you received an 
eye exam. There is no documentation provided that shows whether this exam was for medical purposes or if it 
was a routine exam. Based on this information, we decided that the Plan's rules for coverage of the 
determination of refractive state have been met. You are responsible for anything beyond the $40 allowance. 
Therefore, we decided that the Plan has to pay for the determination of refractive state (92015) provided on 
December 17, 2021 by an out-of-network (OON) provider.  
 
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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 from the hospital there is no documentation 
that you require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Records from the hospital do not clarify that treatment at the skilled nursing facility level is not 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic. 
 
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 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 services are not medically necessary. Our physician reviewer found current clinical guidelines designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. Although records from the device 
manufacturer/vendor argue medical necessity of the requested device, no records from the enrollees actual 
treating provider clarify why the requested device is the most appropriate treatment for the enrollees condition 
are available. 
 
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 MyoPro Motion G orthotic.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81206, 81292, and 81301 provided 
on October 22, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the referring/ordering provider did not write an order for genetic testing for the 
enrollee. This means that the test at issue in this appeal, the genetic testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the genetic testing coded 81206, 81292, and 81301 provided on October 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on September 9, 2016. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing services 
have been met. Therefore, we decided that the Plan has to pay for the drug testing services provided on 
September 9, 2016.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee alignable system. 
 
You asked the Plan to pre-approve the requested services. You say that an alignable system allows necessary 
biomechanical changes to the prosthesis. The Plan denied your request. The Plan says the request does not meet 
medical necessity. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a left below the knee amputation.  The health plan has previously approved a non-alignable lower extremity prosthetic system (L5540). There is no documentation that the alignable system is medically necessary for use with the approved non-alignable system. The provided records do not document the necessity of the alignable system given that the approved prosthesis is a non-alignable system. 
 
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 reqeusted services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a below knee alignable system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network benefit exception for a root canal for 
tooth number 2 to be provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve an in-network benefit exception for a root canal for tooth number 2 to be 
provided by the requested out-of-network provider. You say that you can only drive in familiar areas and due to 
incontinence, you cannot try to search for a rest stop in unfamiliar surroundings. The Plan denied your request. 
The Plan says there are in-network providers in the region with no evidence that in-network specialist resources 
in the same geography to your home have been exhausted. 
 
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. 
 
 We looked at the file and the Plans rules. The Plan offers a dental benefit in excess of Medicare coverage, with 
in-network and out-of-network benefits. The file shows that there are in-network providers in the region with 
no evidence that in-network specialist resources in the same geography to your home have been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve an in-network benefit exception for a root 
canal for tooth number 2 to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart rhythm recording device replacement for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is inappropriate to place an implanted loop recorder indefinitely for a prior event. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for explant of the patients old implantable loop 
recorder (ILR) and placement of a new ILR is medically necessary. There is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR since 
ILR since placed. In summary, there is insufficient documentation to support the medical necessity for insertion 
of an ILR in this patients clinical management. 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heart rhythm recording device replacement for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), a sinus 
augmentation with a vertical approach on tooth #3 and tooth #12 (D7952), a bone graft at the time of implant 
placement on tooth #7 and tooth #10 (D6104), a guided tissue regeneration procedure on tooth #7 and tooth 
#10 (D4266), an unspecified periodontal procedure (D4999), and an unspecified oral surgery procedure 
(D7999) provided by on February 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not pay anything for the dental 
services because of an unlimited $0 copayment. The Plan denied your request. The Plan says the decision to 
deny payment of the requested dental services was correct. The Plan says you had already reached the benefit 
maximum for the panoramic image on the date of service at issue.  You received a panoramic radiograph on 
March 17, 2021, meaning you would not be eligible for coverage of this imaging until 2024. The Plan also 
contacted the provider to confirm that the unspecified periodontal procedure (D0330) was for a retention 
pin and the unspecified oral surgery procedure (D7999) was for a surgical tray. These services in addition 
to the sinus augmentation, bone graft, and guided tissue regeneration are not covered benefits because 
they are either explicitly mentioned in the dental benefit chart as non-covered services or they are not 
mentioned at all, which the Plan clearly indicates is grounds for non-coverage. 
 
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 a 
panoramic radiographic image (D0330), a sinus augmentation with a vertical approach on tooth #3 and tooth 
#12 (D7952), a bone graft at the time of implant placement on tooth #7 and tooth #10 (D6104), a guided tissue 
regeneration procedure on tooth #7 and tooth #10 (D4266), an unspecified periodontal procedure (D4999), and 
an unspecified oral surgery procedure (D7999) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe eyeglass frames (V2025), progressive lens 
(V2781), polycarbonate or equal lens (V2784), and vision supply (V2797) provided on January 5, 2022. 
 
You asked the Plan to pay for the deluxe eyeglass frames, progressive lens, polycarbonate or equal lens, and 
vision supply. You say that you went through the Plan's book and understood that the enrollee has coverage for 
these services. The Plan denied your request. The Plan says this claim processed according to the supplemental 
benefit. The Plan also says that the vision supply (V2797) is not listed as a covered benefit. 
 
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 a $100 maximum for eyewear every 2 calendar years. 
 
We looked at the file and the Plan's rules. The record shows that the Plan applied the enrollee's $100 eyewear 
maximum toward this claim for the January 5, 2022 date of service, and the enrollee's eyewear benefit has been 
exhausted. Vision supply (V2797) is also not listed as a covered benefit. Based on this information, we decided 
that the Plan's rules for coverage of the deluxe eyeglass frames, progressive lens, polycarbonate or equal lens, 
and vision supply have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe 
eyeglass frames (V2025), progressive lens (V2781), polycarbonate or equal lens (V2784), and vision supply 
(V2797) provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81275, 81276 and 81301) 
provided on April 5, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare billing regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81275, 81276 and 81301) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental assessment (D0191) provided by a participating 
provider on January 31, 2022. 
 
You asked the Plan to pay for a dental assessment. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says D0191 is not a covered 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, 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 a dental 
assessment (D0191) provided by a participating provider on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coronectomy partial tooth removal (D7251) provided by an 
out-of-network provider on January 4, 2022. 
 
You asked the Plan to pay for a coronectomy partial tooth removal. You say that you believe the Plan should 
pay for this. The Plan denied your request. The Plan says D7251 is not a covered 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 pay for a 
coronectomy partial tooth removal (D7251) provided by an out-of-network provider on January 4, 2022.