Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not support 
that you require home health skilled nursing care or home health skilled therapy. The records do not support 
that home health aide services are reasonable and medically necessary for the treatment of your illness or injury 
by skilled professional staff. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) home health physical therapy visits (CPT code 
G0151 x10). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) home health physical therapy visits (CPT code 
G0151 x10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction (D7210). 
 
You asked the Plan to pre-approve extraction. You say that you cannot eat due to the pain. The Plan denied 
your request. The Plan says the general dentist did not request the extraction. 
 
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. There is no documentation from the dentists at issue that support that a 
dental extraction is planned or reasonable and necessary. Since you are approved for the consultation, if the 
oral surgeon requests a dental extraction, approval can be requested at that time. Therefore, we decided that the 
Plan does not have to pre-approve the extraction (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
hydraulic swing phase control, with miniature high activity frame (L5826). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced knee. You say that the requested 
prosthetic is medically necessary. The Plan denied your request. The Plan says the requested prosthetic does 
not meet criteria. 
 
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 a prosthetic leg with an advanced knee. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found according to Medicare additional features or components to a 
prosthesis may be necessary depending on the beneficiarys potential functional abilities. Potential functional 
ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering multiple 
factors. These factors include your past history, current condition including the status of the residual limb and 
the nature of the other medical problems and your desire to ambulate. A level 3 ambulator has the ability or 
potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to 
traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands 
prosthetic utilization beyond simple locomotion. In this case, the requested advanced knee is not medically 
necessary as the medical documentation does not support that you are a K3 level ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a prosthetic leg with an advanced knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
hydraulic swing phase control, with miniature high activity frame (L5826).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth-soft tissue (D7220) provided 
on January 28, 2022. 
 
You asked the Plan to pay for the removal of impacted tooth (D7220). The Plan denied your request. The Plan 
says the service provided 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 
removal of impacted tooth-soft tissue (D7220) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation 
(D0140), periapical x-ray (D0220), root canal (D3310), cone beam computed tomography (CT) capture with 
interpretation (D0364), pulp vitality tests (D0460), therapeutic parenteral drugs (D9612), and post and core in 
addition to a crown (D2954) provided on February 28, 2022, by the out-of-network provider. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you explained to a 
plan representative that you needed an in-network dentist that you could see the same day due to your pain 
level. You say that you had no choice but to go out of network. You also say that you feel you should not be 
penalized for the plan's mistakes. The Plan denied your request. The Plan says that the services received from 
the out-of-network provider were 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT, pulp vitality test, 
and therapeutic parenteral drugs are not among those covered under this benefit regardless of the providers 
network status. The record shows there is a 50% coinsurance for covered dental services received out-of-
network. The record also shows that you were given in-network providers prior to the date of service. 
Therefore, we decided that the Plan does not have to reimburse an additional amount for the limited oral 
evaluation (D0140), periapical x-ray (D0220), root canal (D3310), cone beam computed tomography (CT) 
capture with interpretation (D0364), pulp vitality tests (D0460), therapeutic parenteral drugs (D9612), and post 
and core in addition to a crown (D2954) provided on February 28, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331), rubber dam 
(D3910), canal preparation and fitting of preformed dowel or post (D3950). 
 
You asked the Plan to pre-approve treatment of root canal obstruction, rubber dam, and canal preparation and 
fitting of dowel. You say that you need these services. You also say that you cannot afford to get any 
infections. The Plan denied your request. The Plan says the requested treatment of root canal obstruction, 
rubber dam, and canal preparation and fitting of dowel 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
treatment of root canal obstruction (D3331), rubber dam (D3910), canal preparation and fitting of preformed 
dowel or post (D3950).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements) (81162) and 
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast 
and ovarian cancer) gene analysis; full sequence analysis (81163). 
 
You asked the Plan to pre-approve BRCA genetic testing. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says Medicare does not cover BRCA 
genetic testing for breast cancer risk if the enrollee does not have a personal history of breast, ovarian, or 
pancreatic cancer. It's considered to be screening and is specifically excluded by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of BRCA genetic testing have not been met. The records show that testing of individuals with no 
personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is 
considered screening and is excluded by Medicare. Therefore, we decided that the Plan does not have to pre-
approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary 
breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (i.e., 
detection of large gene rearrangements) (81162) and BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis (81163).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dermatology visits (99203, 11102) 
provided on January 19, 2022, and January 25, 2022. 
 
You asked the Plan to waive the copayment for a dermatology office visit. You say that you were told you had 
coverage. The Plan denied your request. The Plan says this processed correctly. 
 
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 $25 
copayment for services provided in a specialist's office.  
 
You have been asked to pay a $25 copayment for each dermatology visit. A dermatologist is considered a 
specialist. 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 dermatology visits (99203, 11102) provided on 
January 19, 2022, and January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is required. The 
Plan denied your request. The Plan says there has been no recent decrease in function. Daily skilled care is not 
required. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that the requested SNF care is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has a history of dementia, stroke, Parkinson's disease, and was recently admitted for COVID-19 
respiratory failure. The documentation shows that the enrollee requires skilled speech therapy for dysphagia. 
The enrollee has multiple medical conditions and would require the assessment and monitoring of a skilled 
nurse. However, the clinical documentation shows that enrollee has advanced dementia and failure to thrive, 
but she is not shown to be beneath her functional baseline. This does not support that daily skilled therapy is 
required, and there is no documentation to show that the enrollee requires daily skilled nursing. As a practical 
matter, the enrollee does not require the necessary care to be provided, on an inpatient basis, in the SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family 
practice physician for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your 
request. The Plan says this item is considered experimental and investigational. There is insufficient evidence 
of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months for an oxygen concentrator 
(E1390). 
 
You asked the Plan to pre-approve additional rental months for an oxygen concentrator. You say that the 
additional rental months for a concentrator is medically necessary. The Plan denied your request. The Plan says 
the enrollee's 36-month rental period is now up and is now considered a purchase. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show you have used 36 months of this service and the 
oxygen concentrator is now considered a purchase. Based on this information, we decided that Medicare rules 
for coverage of additional rental months for an oxygen concentrator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional rental months for an oxygen concentrator (E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 13 
individual codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this NGS panel cannot be billed with multiple codes. One panel code 
should be reported. 
 
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 
March 1, 2022, billed with 13 individual codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the two-day inpatient hospital stay, the three 
consultations with physicians, and pulmonary function testing provided from November 23, 2021, through 
December 21, 2021. 
 
You asked the Plan to waive the charges for the medical services provided. You say that you are being charged 
for services that should be covered. The Plan denied your request. The Plan say that the correct cost sharing 
was applied to 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 describes the cost sharing for 
the services at issue in this case.   
You have been asked to pay $600 for the two days of inpatient hospital care. You have been asked to pay a $25 
copayment for each of the three physician visits you received during this period. Finally, you were assessed 
20% coinsurance for the pulmonary function testing. 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 charges for the 
two-day inpatient hospital stay, the three consultations with physicians, and pulmonary function testing 
provided from November 23, 2021, through December 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for seventy-two (72) additional routine 
transportation trips. 
 
You asked the Plan to provide coverage for seventy-two (72) additional routine transportation trips. You say 
that you have upcoming dialysis treatment 6 times per week and you need additional transportation. The Plan 
denied your request. The Plan says you have exhausted the routine transportation benefit for this year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for seventy-two (72) additional routine transportation 
trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee's spouse is fearful to take the 
enrollee home due to his being a fall risk. The Plan denied your request. The Plan says the enrollee exceeds 
mobility criteria for a SNF admission. The Plan says that the enrollee would be equally well served at an 
alternative level of care, such as a discharge to home with home health care services and assistance from family 
as needed.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to activities of daily living with minimal supervision.  Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower level 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.