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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing needs identified 
or documented. At the current functional level, the enrollee does not require 3 hours a day five days a week of 
IRF therapies with interdisciplinary management. The lack of complexity of the enrollee's medical condition 
and lack of nursing needs do not support an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitation care. The documentation does not support the medical necessity for admission to an 
IRF. The enrollee's rehabilitation needs can be provided in an alternate and low intensity setting. 
 
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 dental extraction you had on January 5, 2022. 
 
You asked the Plan to pay for the dental extraction. You say that you do not have an in-network dentist in your 
area and you would like this claim to be considered for payment. The Plan denied your request. The Plan says 
extractions are not covered under 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. Your dental plan only covers 
the following dental services: exams, x-rays, cleanings, periodontal maintenance, fluoride, fillings, and 
anesthesia.  Extractions are not covered, regardless of the network status of the dentist you see. 
 
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 dental 
extraction you had on January 5, 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 the enrollee requires IRF care to be healthy. The 
Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 shower chair (E0247). 
 
You asked the Plan to pre-approve a shower chair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the requested item is non-covered. 
 
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 (E0247).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the at-home COVID-19 test kits 
purchased on January 17, 2022. 
 
You asked the Plan to provide reimbursement for the at-home COVID-19 test kits. You say that this is covered 
due to an executive order and should be reimbursed. The Plan denied your request. The Plan says the executive 
order regarding this coverage applied only to commercial health plans and not Medicare Advantage plans. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement is offered for home COVID 
testing kits provided after April 4, 2022. 
 
We looked at the file and Medicare rules. These test kits were purchased before Medicare coverage for the kits 
was allowed. Based on this information, we decided that Medicare rules for coverage of the at-home COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for 
the at-home COVID-19 test kits purchased on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network 
provider on February 10, 2022. 
 
You asked the Plan to pay for the out-of-network dental services. You say that the services from the out-of-
network dentist were less expensive than what it would have cost in-network, so the Plan should cover them. 
The Plan denied your request. The Plan says dental services you received from an out-of-network dentist are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan documents clearly 
state that dental services you receive out-of-network are not covered.  This is true even if they are less 
expensive than in-network services. 
 
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 dental 
services you received from an out-of-network provider on February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from April 8, 2021, to May 8, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 a $184 
copayment per day for days 21 to 100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $2,024 copayment for days 21 to 32 of SNF services ($184 x 11 = $2,024). 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 copayment for skilled nursing facility (SNF) services provided from April 
8, 2021, to May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on September 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel detects genomic alterations. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel 
provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing identified with codes 81206, 81292, and 
81301 provided on September 13, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
 We find that CPT codes 81206, 81292, and 81301 are not supported in the medical record. Specifically, if a 
laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered 
part of the same panel. A panel constitutes a single procedural service, so one code should be submitted for the 
panel. Review of the file shows that more than one code was submitted for the services rendered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the genetic testing identified with codes 81206, 81292, and 
81301 provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and 
segmental pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that this enrollee 
has been compliant with greater than 4 weeks of conservative treatments with failure and serial measurements 
and trial documents for support. It is clear that this enrollee qualifies for a basic pump. The Plan denied your 
request. The Plan says the records do not show that the enrollee meets the Medicare criteria. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review indicates that the enrollee is an 80 yo female 
with bilateral lower extremity edema. There is no documentation provided of previous conservative treatments; 
no office notes were provided. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
 
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 pneumatic compression device and appliance have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and 
segmental pneumatic appliance (E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography 
(PET), perfusion study (78492). 
 
You asked the Plan to pre-approve the PET scan. You say that please review this case and allow the enrollee to 
have the PET stress done in your office. The Plan denied your request. The Plan says the records do not support 
that the enrollee meets the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of coronary arteriography five years ago showing insignificant 
coronary artery disease. The enrollees pre-test probability for an abnormal test is low and there is no 
documentation that the ECG shows an uninterpretable pattern. There is no evidence provided that would 
support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the 
medical necessity for the requested cardiac SPECT imaging in this enrollees clinical management. 
 
 
  
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial imaging, positron emission tomography (PET), perfusion study (78492).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on January 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a list of participating dentists for 
2022 and it contained this dentist's name.  You said that the dental office did not advising you that the dentist's 
participation status had changed. The Plan denied your request. The Plan says services you received from a 
non-participating dentist are not covered. 
 
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. Your Plan does not cover 
services you received from a non-participating dentist.  The dentist you saw is not participating in the Plan.  
The Plan cannot be held responsible for this non-participating dentist's failure to provide you with their current 
participation status.  
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 dental 
services you received from an out-of-network dentist on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services rendered from November 9, 2021 to 
November 16, 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 claim was processed correctly. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract does not list 
a diagnostic consultation for an upper denture as a covered benefit. The Plan contract says that enrollees must 
pay 55% of the allowed amount for an erupted tooth extraction from an out-of-network provider and 50% of 
the allowed amount for anesthesia from an out-of-network provider. 
 
Review of the file shows that you had a diagnostic consultation for an upper denture, an erupted tooth 
extraction, and anesthesia services from an out-of-network provider on November 9, 2021 to November 16, 
2021. The denture consultation is not a covered benefit. You have been asked t pay 55% of the allowed amount 
for the tooth extraction and 50% of the allowed amount for the anesthesia. Given that you saw an out-of-
network provider, you may be responsible for charges beyond the Plans allowed amount. Therefore, we 
decided that the Plan does not have to pay for the dental services rendered from November 9, 2021 to 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the limited oral evaluation. We decided that the Plan does not have to 
pay for the cone beam CT capture. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that the 
cone beam CT capture is not covered and the limited oral evaluation exceeds the benefit limit. 
 
We decided that the Plan has to pay for the limited oral evaluation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that you already received two oral exams for the year 2021; 
however, the submitted documentation states you had a limited oral evaluation on January 18, 2021. The Plan 
has not provided any documentation to show that you had a second oral exam in 2021 prior to the exam on 
October 13, 2021. Therefore, we decided that the Plan has to pay for the limited oral evaluation rendered on 
October 13, 2021. 
 
We also decided that the Plan does not have to pay for the cone beam CT capture. 
 
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 cone beam CT capture is not 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT 
capture rendered on October 13, 2021. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service September 
27, 2021. 
 You asked the Plan to pay for procedure code 99135. You say that this service was necessary to control 
surgical bleeding and increase the visual field during the operation. The Plan denied your request. The Plan 
says no separate payment is made for this code. 
 
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 99135 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99135 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99135 billed for date of service September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2920 and D2950) provided on February 
4, 2022. 
 
You asked the Plan to pay for dental codes D2920 and D2950. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D2920 and 
D2950 are not covered under the Plan's supplemental 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, dental codes D2920 and D2950 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D2920 and D2950) provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service February 7, 2021. 
 You asked the Plan to pay for procedure code A4556. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says no separate payment is made for this code. 
 
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 A4556 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4556 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code A4556 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4556 billed for date of service February 7, 2021.