Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on September 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. You say that it is the responsibility of the facility to obtain a 
prior authorization. The Plan denied your request. The Plan says there is no authorization on file for the 
services rendered. 
 
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 outpatient visit provided on September 28, 
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 domiciliary or rest home visit provided on September 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no referral or authorization on file for 
the services rendered. 
 
 
 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 domiciliary or rest home visit provided on 
September 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 clinical documentation shows that patient has active medical comorbidities 
but no complex functional impairments have been specified (hemarthrosis of single joint) thus the complexity of the patient's documented nursing, medical and rehabilitation needs would not be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied services. The Plan denied your request. The Plan says that the coverage criteria 
has not been met. 
 
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 appears to be dependent on vent support with low likelihood of 
being able to wean and requires short-term additional acute care services that can safely be provided at the 
current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary 
as it would not be clinically advantageous at this time. The completion of treatment at the current facility is 
recommended. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair commode. 
 
You asked the Plan to pre-approve a shower chair commode. You say that you would like reconsideration 
because the requested shower chair commode is medically necessary. The Plan denied your request. The Plan 
says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair commode.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) provided 
on July 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found initial molecular testing without a confirmed diagnosis of MDS on bone marrow is 
not reasonable and 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel (81455) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular partial denture (D5213 and 
D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you would like these dentures approved. 
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 November 9, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary and mandibular partial denture 
(D5213 and D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. 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 meet the 
clinical requirements to be approved. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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 pay for a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided 
to the enrollee on June 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a provider performed diagnostic colon endoscopy, in this case per Medicare a Healthcare Common Procedure Coding System (HCPCS) 
sedation code should be reported for all endoscopic procedures where moderate sedation is inherent to the 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) provided to the enrollee on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64491 and 64490). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee's records show 
they do not have any neck pain. 
 
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 injections. Our physician reviewer 
found there is no documentation to support this request. The request is not medically reasonable and 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections (64491 and 64490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer (D6548) provided on September 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was authorized by the Plan. The 
Plan denied your request. The Plan says this service is not a covered benefit under 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 pay for the 
retainer (D6548) provided on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on April 25, 
2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says per your EOC, this service is excluded from 
coverage. 
 
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 a 
porcelain/ceramic crown (D2740) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the reports attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
 
 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 chiropractic services provided on August 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1/2 and all genetic testing (CPT code(s): 81162, 
81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406 and 81437) 
provided on June 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not meet criteria for genetic testing for inherited malignancy. 
Melanoma and leukemia/lymphoma without further specification does not merit genetic testing.  
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for BRCA1/2 and all genetic testing (CPT code(s): 81162, 81201, 81209, 81218, 81292, 
81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406 and 81437) provided on June 27, 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 this is needed to regain strength in the legs and back. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 clinical documentation does not specify any complex functional deficits 
(generalized weakness) or active medical comorbidities thus the complexity of the patient's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to have the ability to get physical therapy 
and occupational therapy so you can get stronger. The Plan denied your request. The Plan says the requested 
IRF services are not medically necessary. 
 
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 clinical documentation does not specify any complex functional impairments 
(multiple sclerosis is noted as a comorbidity, but only chronic right leg weakness is documented) or active medical comorbidities. Thus, the complexity of your documented nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a high risk for falling and it is not safe 
to discharge her to home. The Plan denied your request. The Plan says the requested IRF services 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 that the clinical documentation does not specify any acute complex functional impairments or active medical issues (patient medically stable in skilled nursing facility setting) thus the 
complexity of the patient's documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the denial for a CGM. The Plan 
denied your request. The Plan says that the coverage criteria has 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM.