Persius/hicric huggingface dataset:
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 that you were admitted for urinary tract infection, sepsis, pneumonia, and emergency 
laparotomy for small bowel resection and repair of cystotomy. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. In conclusion, there is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2781) provided on November 14, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses. You say that you went to this provider to have your eyeglasses 
replaced as quickly as possible. The Plan denied your request. The Plan says out-of-network services are only 
covered in certain limited circumstances. The eyeglasses in question were not urgent or emergent, and they 
could have been received from an in-network provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2781) provided on 
November 14, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant placement (D6010 x 2), and bone replacement 
graft (D7953) provided on November 12, 2021. 
 
You asked the Plan to pay for the implants and bone replacement graft. You say that the services should be 
covered. The Plan denied your request. The Plan says implants to replace a single tooth and bone replacement 
graft are not listed as covered services. 
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 the 
implant placement (D6010 x 2), and bone replacement graft (D7953) provided on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Guardant Reveal diagnostic testing provided on 
November 12, 2021. 
 
You asked the Plan to pre-approve the Guardant Reveal diagnostic testing. You say that this testing was 
deemed medically necessary by the treating physician as it detects circulating tumor DNA in colorectal surgery 
patients after surgery to determine the risk of recurrence. The Plan denied your request. The Plan says although 
this test may be promising, it is still under clinical investigation and is not supported by society guidelines or 
the National Comprehensive Cancer Network (NCCN) guidelines. 
 Medicare rules say that molecular diagnostic laboratory tests such as the Guardant Reveal are subject to the 
MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and unique test identifier. 
 
We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Guardant Reveal diagnostic testing provided on 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the handling and/or conveyance of specimen services 
(99000) provided from November 2, 2021, through November 12, 2021. 
 
You asked the Plan to pay for the handling and/or conveyance of specimen services. You say that you would 
like this claim reprocessed based on medical necessity. The Plan denied your request. The Plan says separate 
payment cannot be made for this service according to Medicare rules. 
 
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 code 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the handling and/or conveyance of specimen services have not been met. Therefore, we decided that the Plan 
does not have to pay for the handling and/or conveyance of specimen services (99000) provided from 
November 2, 2021, through November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Complete Wellness panel and Female-Reproductive 
panel provided on April 27, 2021. 
 
You asked the Plan to pay for the Complete Wellness panel and Female-Reproductive panel. You say that this 
was ordered by the treating physician. The results support that this is medically necessary. The Plan denied 
your request. The Plan says this was a screening panel and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. There is no indication of how the results of this extensive lab testing will be used to treat a specific 
medical problem. Without a record showing that this provider is treating the enrollee, the criteria for coverage 
of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the Complete 
Wellness panel and Female-Reproductive panel provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 PT visits. You say that the enrollee has increased with household and 
functional activity. The Plan denied your request. The Plan says the additional visits are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that you have had prior therapy 
and the documentation does not reveal that you require the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. The reviewer found that the requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. The reviewer found that you have been instructed on an independent home program. 
Therefore, the reviewer found that ongoing skilled therapy is 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 6 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual language in effect that indicates that these services are included in the dialysis payment. 
The Plan denied your request. The Plan says the laboratory tests are included in the dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and periodontal scaling and 
root planing (D4342) provided on November 9, 2021. 
You asked the Plan to pay for the dental services. You say that these services are necessary, and it is difficult to 
find a network provider in your area. The Plan denied your request. The Plan says this claim was processed 
correctly, and your benefits have been applied in accordance with your contract. You had a previous limited 
oral exam on September 29, 2021. This service is only covered once per plan year; therefore, the limited exam 
provided on the date in question exceeds the frequency limitation of your benefit. You have also been charged 
50% coinsurance for the periodontal scaling and root planing. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that one limited oral exam 
is covered per plan year. The contract also says that you must pay 50% coinsurance for periodontal scaling and 
root planing.  
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the documentation shows that 
the limited oral exam is requested in a frequency that exceeds what is covered by this benefit. 
 
In addition, the documentation shows that the provider billed the Plan $291 for the periodontal scaling and root 
planing. The Plan's allowed amount for this service is $155, so that is the price used to calculate your 
coinsurance. You have been asked to pay $77.50 for the periodontal scaling and root planing ($155 x 50% 
coinsurance = $77.50). This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) and periodontal 
scaling and root planing (D4342) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 100 day supply of diabetic test strips. 
 
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 a 90 day supply is approved. 
 
The Plan must follow Medicare rules. Medicare rules say that up to 100 test strips every three months are 
covered for beneficiaries who meet specific criteria. 
 
We looked at the file and Medicare rules. The file does not contain documentation to support that 100 test 
strips per three months are necessary for this enrollee. The Plan made attempts to obtain records but a response 
was not received. The Plan has approved a recurring 90 day supply for the enrollee. 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 100 day supply of diabetic test strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 19, 2021 to 
August 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the RAP claim was not received within five calendar days from the start of care. 
 
The Plan must follow Medicare rules. The rules say that all HHAs must submit a request for anticipated 
payment within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days 
after the from date for each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. The file shows that the claims were not submitted within five 
calendar days of the start of care. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from July 19, 2021 to August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on December 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the enrollee did not come to the lab which 
means they did not use their out-of-network benefits. You say the participating doctor sent the specimen. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for pathology services provided on December 3, 2021, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that notes do not show the enrollee needs intense therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart 
failure after recent coronary artery stent placement, infection of foot, and bacteremia. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says eight (8) additional PT visits are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 eight (8) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. There is no documentation of a 
recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollee's medical condition and therefore 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 eight (8) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that the records provided support the need for RFA 
services. The Plan denied your request. The Plan says the requested service has not been proven by research to 
be helpful. The Plan says that the requested service is considered experimental and investigational. 
 
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 RFA services. Our reviewer says that 
RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
this is considered an experimental/investigational procedure because of the wide variation in efficacy reported 
in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.