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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 30, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately and is 
supported in the medical record. 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 July 30, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 1, 2022, through February 28, 2022. 
 
You asked the Plan to pay for the SNF care provided. You say that the provided care was medically reasonable 
and necessary. The Plan denied your request. The Plan says this facility was not enrolled in the Medicare 
program during the dates of service in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from February 1, 2022, through February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract with the dialysis 
facility for these lab services. The Plan denied your request. The Plan says these lab services are not separately 
payable. 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 lab services provided on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), FreeStyle Libre 
14-day Sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee needs this device. The Plan denied your 
request. The Plan says the criteria have not been 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 and 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 the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM), FreeStyle Libre 14-day Sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy is medically necessary. The 
Plan denied your request. The Plan says additional therapy is 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 therapy 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 based on the available records the enrollee appears to have made 
slow improvement with the therapy provided thus far. Given the additional 10 therapy treatments just 
approved, the records do not support that the complexity of the enrollees conditions are such that the skills of a 
professional therapist are required to achieve further improvement in the enrollees symptoms or functional 
status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010), prefabricated abutments 
(D6056) and implant supported crowns (D6066) for teeth #22 and #27. 
 
You asked the Plan to pre-approve dental implant services. You say that you were under the impression that 
these services could be covered by your plan. The Plan denied your request. The Plan says these services are 
not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve dental implants (D6010), prefabricated 
abutments (D6056) and implant supported crowns (D6066) for teeth #22 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6060). 
 
You asked the Plan to pre-approve an endosteal implant, prefabricated abutment, and abutment supported 
porcelain fused to metal crown. The Plan denied your request. The Plan says these services are not covered 
under your benefit plan. 
 
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 surgical placement of implant body: 
endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal 
crown (D6060).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brand-specific oxygen supplies. 
 You asked the Plan to pre-approve the requested item. You say that you need a portable oxygen concentrator 
that is not too heavy. The Plan denied your request. The Plan says a comparable device on the list of covered 
equipment would be sufficient. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that 
plans may specify brands and manufacturers as preferred. 
 
The requested brand is not a preferred brand with the Plan. The Plan has available brands available for the 
specific item. We found no exception that would require the Plan to pre-approve a non-preferred brand. 
Therefore, we decided that the Plan does not have to pre-approve brand-specific oxygen supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for dietitian services to be provided by 
the requested out-of-network provider. 
 
You asked the Plan to pre-approve an office visit for dietitian services to be provided by the requested out-of-
network provider. You say that that the in-network providers in your area do not specialize in what you need 
and cannot assist with this issue as much as this doctor can. The Plan denied your request. The Plan says the 
Plan covers care from non-participating providers under limited circumstances such as during emergency care 
delivered in an emergency room in the United States or its territories or in the Plans service area when network 
of doctors and other health care professionals, medical groups, hospitals, and other health care facilities cannot 
provide the requested care. 
 
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 for dietitian services to be provided by the requested out-
of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted with altered mental status in the setting of urinary tract 
infection and cirrhosis. The record indicates that the enrollee still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for prophylaxis (D1110), bitewing x-rays 
(D0274), a periodic oral evaluation (D0120), periapical x-ray (D0220), and additional periapical x-rays (D0230 
x 2) provided on February 2, 2022. 
 
You asked the Plan to waive the copayments for prophylaxis, x-rays, and an evaluation. You say that the 
copayments should be waived. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 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 you must pay $15 
copayment per service during the visit for covered in-network routine dental services.  
 
You have been asked to pay a total of $89.04 for the dental services. Prophylaxis, x-rays, and an evaluation 
falls within the Dental Services benefit category.  
 
Code Copayment 
D1110 $15 
D0274 $15 
D0120 $15 
D0220 $15 
D0230 $14.52 
D0230 $14.52 
Total  $89.04 
 
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 waive the copayments for prophylaxis (D1110), bitewing x-rays (D0274), a periodic 
oral evaluation (D0120), periapical x-ray (D0220), and additional periapical x-rays (D0230 x 2) provided on 
February 2, 2022.
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 would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
 
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 pre-approve a retreatment of previous root canal therapy (D3348). 
 
You asked the Plan to pre-approve the retreatment of previous root canal therapy. You say that you cannot 
afford to pay for this service. The Plan denied your request. The Plan says this service is not covered by your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
retreatment of previous root canal therapy (D3348).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided to the enrollee on 
January 21, 2022. 
 
You asked the Plan to pay for the testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that the next generation sequence testing (NGS) testing 
panel performed included testing for FANCC genes. Testing for these genes is not a Medicare benefit and is 
statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
We looked at the file and Medicare rules. The testing was provided to someone with a solid tumor. The FDA 
approval notice indicates that this testing is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the testing 
have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing 
provided to the enrollee on January 21, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 reader. 
 
You asked the Plan to pre-approve FreeStyle Libre 2 reader. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet 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 FreeStyle 
Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Libre 2 reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom abutment (D6057) and abutment supported crown 
(D6058) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says custom abutment (D6057) and abutment supported crown (D6058) are 
not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
abutment (D6057) and abutment supported crown (D6058) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you need this service to get partials The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are visiting in South Carolina and need 
these services. The Plan denied your request. The Plan says that there are network providers available to 
provide this service. 
 
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 Mohs surgery to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buprenorphine. 
 
You asked the Plan to pre-approve buprenorphine. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve buprenorphine.  
 Benefits for buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.