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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be provided safely in other settings, for example, a skilled nursing 
facility, home with home health services or home with outpatient 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.  
 Our physician reviewer found that the enrollee is medically stable and does not need physician supervision 
three times a week in the IRF. There are no acute rehab nursing needs identified or documented. At the current 
level of mobility and activities of daily living, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. There is no 
documentation of necessity for this admission. The enrollee's needs can be safely provided in a lower intensity 
and alternate setting such as in a skilled nursing facility. 
 
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 hearing aids (V5257, V5160, V5299, V5011) provided 
August 27, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that the provider should have checked network status 
prior to rendering services. The Plan denied your request. The Plan says the hearing aids are not covered 
because they were not ordered through the Plan's hearing aid vendor. 
 
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. The Plan pays for 
hearing aids only when purchased through the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not purchased through the Plans 
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257, 
V5160, V5299, V5011) provided August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on May 11, 2022. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the item provided has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the item provided was exhausted on date of service February 26, 2019. Specifically, the 
Plan provides coverage of one partial denture every five years. You previously received this dental item on 
February 26, 2019, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for 
this item. Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5213) 
provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not aware there was a 
wait on comprehensive dental exams. You also say that you do not like dentists, and would have waited if you 
had known. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 27, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assay of magnesium (83735) provided on November 4, 
2021. 
 
You asked the Plan to pay for magnesium testing. You say that this service is supported in the medical record. 
The Plan denied your request. The Plan says the criteria for coverage of this code/service are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 83735. 
 
We looked at the file and Medicare rules. This claim was not billed with a diagnosis code which supports the 
medical necessity of 83735. Based on this information, we decided that Medicare rules for coverage of 
magnesium testing have not been met. Therefore, we decided that the Plan does not have to pay for the assay of magnesium (83735) provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a High-intensity focused ultrasound (HIFU) ablation (55880) 
procedure provided on January 10, 2022. 
 
You asked the Plan to pay for the procedure. You say that this procedure was medically necessary. The Plan 
denied your request. The Plan says this service was experimental in nature and is non-covered. 
 
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 pay for the procedure. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current clinical guidelines support this procedure for the treatment of recurrent cancer when the patient is 
a candidate for local therapy, has had a positive Transrectal ultrasound guided (TRUS) biopsy, and has no 
metastatic disease. The enrollee did not meet these criteria, and this use would be considered investigational. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not have to pay for a High-intensity focused ultrasound (HIFU) ablation (55880) procedure provided on January 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical each additional radiographic image 
(D0230 x 3) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service June 23, 2022. Specifically, on 
June 23, 2022, one intraoral-periapical first radiographic image was provided and paid for by the Plan. On this day, 
three additional intraoral-radiographic images were provided. However, the Plan contract pays for only one 
intraoral x-ray per calendar year.  Therefore, the allowable benefit for these services has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the intraoral-periapical each additional radiographic image (D0230 x 3) provided on  
June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on March 30, 
2022. 
 
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 this code is not separately payable 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on April 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are requesting 
reconsideration of payment on this claim. The Plan denied your request. The Plan says the date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. 
 
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 81455 is not supported in the medical record. Specifically, the specimens were 
collected on March 21, 2022, and March 24, 2022, rather than the billed date of service of April 9, 2022. Based 
on this information, we decided that Medicare rules for coverage of laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services (81455) provided on April 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional fractions of external beam radiation 
therapy (G6013) for the enrollee. 
 
You asked the Plan to pre-approve the additional fractions. You say that this is medically necessary. The Plan 
denied your request. The Plan says no national guidelines recommend using more than ten fractions in the 
treatment of metastatic breast cancer. 
 
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 additional fractions. Our reviewer 
says that the requested additional fractions are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the need for more than the ten approved fractions is not justified in the case 
file. Routinely prescribing more than ten fraction for palliation of bone metastases is not furnished in 
accordance with the accepted standards 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 the additional fractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional fractions of external beam radiation therapy (G6013) for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 10, 2021 billed 
with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. 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 must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 10, 2021 billed with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics (L3010, L3060). 
 
You asked the Plan to pre-approve custom foot orthotics. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
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. Additionally, Medicare rules say that with the exception of the situations described, orthopedic 
footwear billed using codes L3010 and L3060 will be denied as non-covered. Therefore, we decided that the 
Plan does not have to pre-approve custom foot orthotics (L3010, L3060).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computerized tomography (CT) scan provided on March 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for March 8, 2022. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 a computerized tomography (CT) scan provided 
on March 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urology office visit provided on April 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were instructed to see a urologist within two 
days following the results of a previous imaging test. You say you were scheduled to see an in-network 
provider at a later date and contacted the office to try to schedule an appointment sooner. You were told that 
the in-network provider was on vacation and the office scheduled you for an appointment with a different 
provider. You say that you assumed the rendering provider was also in-network because no one informed you 
otherwise. The Plan denied your request. The Plan says the services were rendered by an out-of-network 
provider without a referral from your primary care physician (PCP) or another in-network provider. The Plan 
also says there was no attempt to obtain a 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 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 a urology office visit provided on April 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic comprehensive preventive medicine reevaluation 
provided on March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine reevaluation. You say that you 
would like to request reconsideration for payment. The Plan denied your request. The Plan says these services 
need to be received in-network for reimbursement. 
 
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 periodic comprehensive preventive medicine 
reevaluation provided on March 21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve an auricular stimulator. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says these devices are not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are 
electroacupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not 
have to pre-approve an auricular stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Guardian Link 3 transmitter (K0553). 
 
You asked the Plan to pre-approve a Guardian Link 3 transmitter. You say that the requested devices are 
necessary. The Plan denied your request. The Plan says you do not meet coverage criteria for the requested 
device. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Guardian 
Link 3 transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Guardian Link 3 transmitter (K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest provided on May 17, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the x-ray should be covered because it was requested by 
the surgeon that will be performing surgery on you. The Plan denied your request. The Plan says the x-ray was 
rendered by an out-of-network provider. The Plan confirmed that the surgeon's office does not give referrals to 
specific locations, rather, you would simply go to the nearest walk-in radiology clinic. Since the surgeon did 
not specifically refer you to the rendering facility and the services were not authorized prior to the date of 
service, benefit coverage for the x-ray cannot be granted. 
 
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 an x-ray of the chest provided on May 17, 2022, 
by an out-of-network (OON) provider.