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

 
We decided that the Plan does not have to pay for the infectious agent detection 12-25 targets (87633) provided 
on March 3, 2022. 
 
You asked the Plan to pay for the infectious agent detection (87633). The Plan denied your request. The Plan 
says a laboratory requisition and laboratory results were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious agent detection (87633) have not been met. Specifically, procedure code 87633 is 
not a covered service. Therefore, we decided that the Plan does not have to pay for the infectious agent 
detection 12-25 targets (87633) provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth - partially bony #17 and 
32 and therapeutic parenteral drug. 
 
You asked the Plan to pre-approve removal of an impacted tooth - partially bony #17 and 32 and therapeutic 
parenteral drug. 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. 
 
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 
removal of an impacted tooth - partially bony #17 and 32 and therapeutic parenteral drug.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy visits (CPT code 
G0151 x 12). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
members condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are 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 the home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapy visits (CPT code G0151 x 
12).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (CPT code 33340). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the request for percutaneous transcatheter closure of the left atrial appendage with 
endocardial implant and associated inpatient hospital admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 service. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found guidelines would not support implantation of a LAAC in this setting. In summary, LAAC 
placement would not be considered reasonable or medically necessary in this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter closure of the left atrial appendage with endocardial implant, 
including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage 
angiography, when performed, and radiological supervision and interpretation (CPT code 33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
11, 2021. 
 
You asked the Plan to pay for the requested device. You say that this is a take home item. The Plan denied your 
request. The Plan says the service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
The file shows that the device was prescribed to prevent blood clots. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 14, 2022. 
 
You asked the Plan to pay for a domiciliary, rest home visit. The Plan denied your request. The Plan says the 
Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent 
care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants represented by code D6010. 
 
You asked the Plan to pre-approve endosteal implants. You say that you need to get the dental implants 
because your quality of life has been affected. You say that you are in heavy pain and your dentist explicitly 
stated your mouth and the rest of your teeth could be damaged if the requested procedure isn't performed as 
soon as possible. The Plan denied your request. The Plan says endosteal implants are not covered under the 
benefit plan per the Evidence of Coverage. 
 
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 
endosteal implants represented by code D6010.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for multiple endocrine neoplasia 
syndrome type 1, MEN1. 
 
You asked the Plan to pre-approve genetic testing. You say that all necessary information was not provided 
during review of the original authorization, and based on the additional information provided, it is reasonable 
to screen enrollee for MEN-1 as individuals with multiple endocrine-related including family history with 
similar conditions are highly suspect for this disorder. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for approval of the requested genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that MEN1 are considered medically necessary in 
patients with multiple endocrine neoplasia to guide therapeutic decision-making. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing for multiple endocrine neoplasia syndrome type 1, MEN1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 18, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan has to 
pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and 
pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional hours of in-home services. 
 
You asked the Plan to pre-approve 60 additional hours of in-home services. You say that you are currently 
paying out-of-pocket for this service, but your funds are very limited. You say that you have used the 60 hours 
for the year and are requesting 120 hours a year. The Plan denied your request. The Plan says you have 
exhausted your 60-hour benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 60 additional hours of in-home services have not been met. Specifically, you have exhausted the 
60-hour benefit. Therefore, we decided that the Plan does not have to pre-approve 60 additional hours of in-
home 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week 
of rehabilitative services with regular physician evaluation. The enrollees care needs can be met at a lower 
level of 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that the transportation is necessary. The Plan 
denied your request. The Plan says the benefit is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition of a metatarsal pad to your existing foot 
orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve the addition of a metatarsal pad to your existing foot 
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lenses, polycarbonate or equal, any index (V2784),
progressive lenses (V2781), anti-reflective coating (V2750), and deluxe frames (V2025) provided May 3, 2022,
by an out-of-of-network (OON) provider.

You asked the Plan to pay for the routine eyewear. You say that you thought your glasses would be covered
since your eye exams are covered at this location. The Plan denied your request. The Plan says the routine
eyewear is not covered because it was provided OON.

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 purchased form a provider in the Plan's third-party vision
vendor's network.

We looked at the file and the Plan's rules. In this case the routine eyewear was purchased OON. 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 lenses, polycarbonate or equal, any index (V2784),
progressive lenses (V2781), anti-reflective coating (V2750), and deluxe frames (V2025) provided May 3, 2022,
by an out-of-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi precision attachment (D6192), an endosteal 
implant (D6010), a bone graft (D6104), guided tissue generation (D4266), semi-precision abutment (D6191), 
and an unspecified removable prosthodontic procedure (D5899), provided by a participating provider. 
 
You asked the Plan to pre-approve a semi precision attachment, an endosteal implant, a bone graft, guided 
tissue generation, semi-precision abutment, and an unspecified removable prosthodontic procedure. You say 
that these services are medically necessary. The Plan denied your request. The Plan says the requested dental 
services are not covered 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 
semi precision attachment (D6192), an endosteal implant (D6010), a bone graft (D6104), guided tissue 
generation (D4266), semi-precision abutment (D6191), and an unspecified removable prosthodontic procedure 
(D5899), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removable unilateral partial denture (D5282) provided by a 
participating provider on June 16, 2022. 
 
You asked the Plan to pay for a removable unilateral partial denture. You say that you were never told that 
these services were out-of-network. The Plan denied your request. The Plan says the rendered dental work 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 
removable unilateral partial denture (D5282) provided by a participating provider on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on May 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to have the bridge fixed or you 
would have to have two additional teeth pulled. The Plan denied your request. The Plan says fixed partial 
denture sectioning (D9120) is not covered by your routine dental 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 pay for fixed 
partial denture sectioning (D9120) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (X4 (D4921), periodontal 
scaling and root planing one to three teeth per quadrant (x4), drugs or medicaments dispensed in the office for 
home use (D9630) and Localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (x2) (D4381) provided on March 25, 2022. 
 
You asked the Plan to pay for dental services. You say that you feel the charges are too high for only a 
cleaning. The Plan denied your request. The Plan says the member did not contact the Plan prior to the date of 
service to verify benefits and provider eligibility. Also, there is no coverage for services billed. 
 
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 gingival 
irrigation - per quadrant (X4 (D4921), periodontal scaling and root planing one to three teeth per quadrant (x4), 
drugs or medicaments dispensed in the office for home use (D9630) and Localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (x2) (D4381) provided on 
March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5225) provided March 17, 2022. 
 
You asked the Plan to pay for the upper partial denture. You say that you were unaware that this location would 
not be covered. The Plan denied your request. The Plan says services provided in a dental laboratory 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.  
 
 
 
 
 
 We looked at the file and Medicare rules. The services in this case were performed by a dental laboratory 
technician. Based on this information, we decided that the Plan's rules for coverage of the upper partial denture 
have not been met. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture - 
flexible base (including retentive/clasping materials, rests, and teeth) (D5225) provided March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on May 4, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on May 4, 2022.