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

 
We decided that the Plan does not have to pre-approve breast implant removal with capsulectomy. 
 
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 breast implant removal 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 the enrollee has bilateral contractures 
and has appreciated an increase in breast firmness over the past few years. The record does not indicate that the 
contractures are painful and cause disfigurement. The criteria for coverage are not met and the services are 
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 breast implant removal with capsulectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided August 19, 2021.

You asked the Plan to pay for the limited oral exam. You say that the exam was necessary to evaluate your
crown. 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 Plan's coverage rules apply in this case. The Plan covers the limited
oral exam once per plan year.

We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam
was previously covered on March 29, 2021.

Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has
been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation -
problem focused (D0140) provided August 19, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to waive the copayments for home health agency care provided from January 1, 
2021, to March 9, 2021. 
 
You asked the Plan to waive the copayments for home health agency care. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are 
being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for home health agency care.  
 
The Plan says you must pay a $25 copayment for home health agency care. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for home health agency care. Therefore, we 
decided that the Plan has to waive the copayments for home health agency care provided from January 1, 2021, 
to March 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services and subsequent hospital care 
services provided on April 12, 2021 and April 13, 2021. 
 
You asked the Plan to pay for the initial hospital care services and subsequent hospital care services. You say 
that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the claim 
submitted is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99221 and 99231 are not supported in the medical record. Specifically, the 
documentation shows that these codes were previously paid for these dates of service. Both providers that 
billed these services have the same specialty and same group practice. This means this claim is a duplicate to a 
claim previously processed and paid by the Plan. This claim is not separately payable. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services and subsequent 
hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial hospital care services and subsequent hospital care services provided on April 12, 2021 and April 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 24, 2021 and 
billed under code 81479. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this test is not covered for screening purposes when the results will not be used to 
determined treatment. 
 
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. The test at issue in this appeal 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 lab services provided to the enrollee on May 24, 2021 and billed under 
code 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SmartPill wireless capsule. 
 
You asked the Plan to pre-approve the requested services. You say that the test is being used to determine 
where the enrollee's dysmotility is located. The Plan denied your request. The Plan says there is a lack of 
evidence demonstrating clinical utility over conventional means of measuring gastric emptying. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is only covered under 
certain medical indications.  
 
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 reported random nausea, early satiety, and fullness despite Reglan use. An 
esophagogastroduodenoscopy (EGD) proved normal, but an upper gastrointestinal series raised concern for 
early achalasia. A wireless motility capsule has not been widely accepted as standard of care in clinical practice 
outside of tertiary care specialty centers and is not more readily available than gastric motility or colon transit 
testing. Furthermore, data are insufficient to determine the optimal timing of the requested service in the 
enrollees case of known gastroparesis and suspected diabetic gut neuropathy. Medical necessity for the 
requested service is not apparent from the enrollees provided record, nor do the records support that the 
coverage criteria applies to 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SmartPill wireless capsule.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the records provided do not 
indicate that the guidelines for coverage of inpatient psychiatric care have been met. The Plan says that the 
enrollee could be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
  
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found you were 
admitted to the acute inpatient psychiatric hospitalization on November 12, 2021, with Schizophrenia 
Unspecified. Based upon review the records provided it was not expected that you would improve in a 
reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or 
others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and cooperative 
with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have 
any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve your condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that you have an appointment set up with this 
provider and your specialist told you to acquire a second opinion. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because this provider is out-of-network with the plan and 
you can be treated by an in-network specialist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you life would be in 
danger if the services were not approved. You say that there is not a safe discharge plan and you have anxiety. 
The Plan denied your request. The Plan says you no longer meet the criteria for this requested level of care. 
The Plan says that care at a less restrictive level would be more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found you were 
admitted to the acute inpatient psychiatric hospitalization on November 16, 2021, with Generalized Anxiety 
Disorder and Unspecified Mood Disorder. Based upon review the records provided it was not expected you 
would improve in a reasonable period of time beyond the dates in question as you were not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were 
compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as you did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. It 
did not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225) and a partial lower 
denture (D5226). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that you had 
seven teeth extracted and the partials you received in August have metal which are affecting your good teeth 
and causing your front teeth to space from one another. You also say your front teeth are not holding up 
together and causing problems with your gums because of the lack of support from the partial dentures 
previously done. The Plan denied your request. The Plan says the services exceed the benefit allowance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a partial 
upper denture and a partial lower denture once every 60 months.  
 
 We looked at the file and Medicare rules. The records show that you received an upper and lower partial 
denture (D5211 and D5212) on August 2, 2021, therefore, you have exhausted your maximum benefit for this 
service. Based on this information, we decided that the Plan's rules for coverage of a partial upper denture and a 
partial lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5225) and a partial lower denture (D5226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgical services provided to the enrollee on March 
29, 2021. 
 
You asked the Plan to pay for the services. You say that the services The Plan denied your request. The Plan 
says the documentation submitted indicates that assistant surgical services were performed by a Surgical 
Technologist/Surgical First Assistant (CST/CSFA) 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant surgical services provided 
to the enrollee on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) to be rendered by a non-participating provider. 
 
You asked the Plan to pre-approve a core buildup. You say that you are requesting reconsideration of the denial 
for dental services. The Plan denied your request. The Plan says this service is not listed as 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 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 a 
core buildup, including any pins when required (D2950) to be rendered by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio test strips.

You asked the Plan to pre-approve One Touch Verio test strips. You say that the documentation provided supports the need for diabetic testing strips. The Plan denied your request. The Plan says their preferred blood glucose meters and test strips are Abbott Diabetes Care Strips and Ascencia Diabetes Care Strips.

The Plan must follow Medicare rules. Medicare rules say that plans can limit coverage of DME to preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items. 

We looked at the file and Medicare rules. The case file shows that One Touch Verio test strips are a non-preferred brand/provider. The Plan has preferred brands that can supply diabetic test strips when medically necessary. There is no evidence that the Plan's preferred brands would be insufficient for the enrollee. Based on this information, we decided that Medicare rules for coverage of non-preferred brand test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and testing to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you are concerned your body will reject foreign materials. The Plan denied your request. The Plan says there are services available in your network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit and testing to be provided by an out-of-network (OON) provider.
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 records provided support the need for IRF care. 
You say that the enrollee has medical concerns that would be treated better in an IRF so that she can be 
watched closely. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee can safely receive the services needed 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. Our physician reviewer found at the current medical stability and lack of medical complexity, there is no need for 
physical medicine and rehabilitation (PMR) physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no 
acute nursing care needs. Based upon the enrollee's current level of function, she does not require intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy. The enrollee needs physical therapy and occupational therapy in an alternate and low 
intensity level. While the enrollee may benefit from physical and occupational therapy, her rehabilitation needs 
can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF.) 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (95925) provided on May 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this service is not 
payable. 
 
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. The Plan argues that code 95925 is not payable due to an NCCI column 
I/column II edit. In this case, code 95925 was billed for date service May 13, 2021, with codes 95955 and 
G0453. A column I/column II edit does not exist between code 95925 and these codes. The Plan has not 
provided documentation showing that code 95925 is not payable as billed. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services 
(95925) provided on May 13, 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.