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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records show that it is not reasonable to expect that the enrollee 
would need, nor would fully benefit from, the intensity of services of an IRF. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture and subsequent fall with facial fractures managed 
without surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient mental health care. 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
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 this service.  Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that the 
enrollee was involuntarily admitted for an acute inpatient psychiatric hospitalization on December 8, 2022 with 
Major Depressive Disorder, Recurrent without Psychotic Features, Generalized Anxiety Disorder, Post 
traumatic stress disorder (PTSD), History of an Eating Disorder, History of a Poly Substance Use Disorder, 
Borderline Personality Disorder, and Alcohol Use Disorder. Based upon the review of the records provided, it 
was not expected that this enrollee would improve in a reasonable period of time as she did not have 
dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive 
behaviors. 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 as she did not have dangerousness to self or others. The 
health plans denial of acute inpatient mental health treatment appears appropriate. This enrollee does not 
appear to require inpatient mental health treatment as she was not a danger to herself or others and was 
cooperative with care without any aggressive behaviors. It does not appear that active treatment was taking 
place. It does not appear that the requested services are reasonably expected to improve the enrollees condition 
or that the requested services are for the purpose of a diagnosis. It does appear that the records were supervised 
and evaluated by a physician. Based upon the review of the records provided, the enrollee does not meet 
criteria for coverage of acute inpatient mental health treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee so 
they can monitor their glucose levels. The Plan denied your request. The Plan says the Medicare criteria was 
not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on November 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. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and a crown (D2740). 
 
You asked the Plan to pre-approve  core buildup and a crown. You say that these services should be covered. 
The Plan denied your request. The Plan says the crown is not medically necessary, and the core buildup 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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 a crown. Our reviewer says that the 
service is not medically necessary.  Our reviewer found that there is no clear indication that a crown should be 
approved for tooth #31 given the current condition of the root canal fill. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a core buildup and a crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core buildup (D2950) and a crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the 
claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid repair/modification (V5014) provided on 
February 8, 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. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the service provided in this case is not a covered 
benefit under the supplemental benefit policy. Therefore, we decided that the Plan does not have to pay for the 
hearing aid repair/modification (V5014) provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
17, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar spine fusion (22612). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing the denial because 
you need relief, and this is your only hope. The Plan denied your request. The Plan says the Lumbar Spine 
Fusion are considered 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no spinal instability or fracture. Fusion is not medically needed for 
degenerative back pain. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the lumbar spine fusion (22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during removal of 
implant and tendon or muscle repair provided on April 28, 2022. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 the assistant surgeon services 
provided during removal of implant and tendon or muscle repair provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Type 2 diabetes with 
severe right eye non-proliferative diabetic retinopathy with macular edema. He has not tried and failed the 
Plan's required drugs, Byooviz or Cimerli. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Vabysmo is 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 Vabysmo.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden 
variant. You say that this testing is medically necessary. The Plan denied your request. The Plan says this 
testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. genetic testing for F2 and F5 genes for all risk factors, signs, symptoms, 
diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), mechanical 
traction therapy (97012), and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider 
on January 2, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the chiropractic manipulative treatment (98941), mechanical traction therapy 
(97012), and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider on January 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your Plan benefits. Coverage may 
be provided by your former employer/union/trust, however, it shows that dental implants is the only covered 
service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) 
provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gainswave treatment provided from July 7, 2022, to 
October 6, 2022. 
 
You asked the Plan to pay for the Gainswave treatment. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0101T is extracorporeal shock wave involving 
musculoskeletal system, not otherwise specified. 
 
We find that CPT code 0101T is not supported in the medical record. Specifically, the documentation shows 
that Gainswave treatment for male erectile dysfunction was performed. There is a more appropriate code to be 
billed for this service rendered. Based on this information, we decided that Medicare rules for coverage of the Gainswave treatment have not been met. Therefore, we decided that the Plan does not have to pay for the 
Gainswave treatment provided from July 7, 2022, to October 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75820 billed for date of service November 
10, 2022. 
 You asked the Plan to pay for procedure code 75820. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 75820 is bundled into 
payment for code 77001. 
 
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, we have confirmed that code 75820 
is a column II code to column I code 77001. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 75820 billed for date of service November 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 21248, 21079, 21215, 21210, 41874, 21025, and 
21030 provided on March 29, 2022. 
 
You asked the Plan to pay for codes 21248, 21079, 21215, 21210, 41874, 21025, and 21030. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
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 21248, 21079, 21215, 21210, 41874, 21025, and 21030 are not supported in the 
medical record. Specifically, these services were provided during the global surgical period of surgery 
procedure 21085 (impression and custom preparation; oral surgical splint). This means these codes are not 
separately payable.  Based on this information, we decided that Medicare rules for coverage of codes 21248, 21079, 21215, 21210, 
41874, 21025, and 21030 have not been met. Therefore, we decided that the Plan does not have to pay for 
codes 21248, 21079, 21215, 21210, 41874, 21025, and 21030 provided on March 29, 2022.