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

 
We decided that the Plan does not have to pay for lab services (81479) provided on August 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation with a medicinal agent, application of 
desensitizing medicament, occlusal adjustment, bitewing x-ray, core buildup, and comprehensive periodontal 
evaluation (D4921, D9910, D9951) provided on October 7, 2021, to November 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plan's 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 August 3, 2020 (D0180) 
and October 7, 2021 (D0272, D2950). Therefore, we decided that the Plan does not have to pay for gingival 
irrigation with a medicinal agent, application of desensitizing medicament, occlusal adjustment, bitewing x-ray, 
core buildup, and comprehensive periodontal evaluation (D4921, D9910, D9951) provided on October 7, 2021, 
to November 4, 2021.
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 continuing therapy both physical therapy and 
respiratory, monitored shifts of rehabilitation would benefit the enrollee tremendously. 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two endosteal implants (D6010), surgical extractions 
(D7210), an alveoloplasty (D7311), and a bone replacement graft for ridge preservation (D7953) provided on 
May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you need the rest of this dental work. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 $4,000 annual dental allowance amount was exhausted on date of service May 23, 2023. Therefore, 
we decided that the Plan does not have to pay for two endosteal implants (D6010), surgical extractions (D7210), an alveoloplasty (D7311), and a bone replacement graft for ridge preservation (D7953) provided on 
May 23, 2023.
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pain after recent lumbar spinal fusion. The enrollee's medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of 
care. There is not a reasonable expectation that this 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 pay for a continuous glucose monitor (CGM) provided by an out-of-
network provider on June 24, 2023. 
 
You asked the Plan to pay for the CGM. You say that the CGM was medically necessary for the enrollee. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM. Our reviewer says that the CGM 
coverage criteria was not met. Our physician reviewer found that the record indicates that the enrollee has 
diabetes. The record provided does not indicate that the enrollee has had an in-person or Medicare-approved 
telehealth visit with the treating practitioner to evaluate their diabetes control and to document that the 
coverage criteria are satisfied within 6 months prior to the ordering the requested device. The provided records 
are insufficient to establish that the coverage criteria are satisfied. The elements of the coverage criteria are not 
satisfied. The requested service is not 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pay for a continuous glucose monitor (CGM) provided by an out-of-network provider on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a denture tooth replacement (D5640) provided on August 1, 
2023. 
 
You asked the Plan to pay for D5640. You say that you need these teeth fixed. The Plan denied your request. 
The Plan says the rendered dental service is not a covered 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 pay for a denture 
tooth replacement (D5640) provided on August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the backrest release bar (K0108). 
 
You asked the Plan to pre-approve the backrest release bar. You say that the item should be covered. The Plan 
denied your request. The Plan says this is an item of convenience. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the backrest release bar (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
  You asked the Plan to pre-approve the injection. You say that the patient has been on conservative therapy 
since 2022 which includes physical therapy, home exercise program, and non-steroidal anti-inflammatory 
drugs within the past 12 months. The Plan denied your request. The Plan says an epidural steroid injection is 
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 pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the imaging does not 
identify a lesion that corresponds to the pain. Therefore, the LCD coverage criteria has not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691), provided 
on July 18, 2023. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the records do not mention a diagnosis of psoriasis or a history of 
psoriasis 
 
The Plan must follow Medicare rules. Medicare rules say that that a UV light therapy system is covered for 
selected patients with generalized intractable psoriasis. Using appropriate consultation, the MAC should 
determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., 
outpatient department of a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the UV light therapy system have not been met. Therefore, we decided that the Plan does not have 
to pay for the ultraviolet (UV) light therapy system (E0691), provided on July 18, 2023.
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 the enrollee's hospital course has been 
extensive and they are ready for transfer to an LTACH. The Plan denied your request. The Plan says the 
request 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the Plan. The enrollee still 
requires an inpatient level of care but does not require the LTACH. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (E2103) and supplies 
(A4239), provided on June 7, 2023. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was discussed or that a referral was sent to this provider. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (E2103) 
and supplies (A4239), provided on June 7, 2023.
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 this level of care. The Plan denied 
your request. The Plan says medical records do not support the need for an IRF admission and, the enrollee 
needs can be safely provided at another setting.  
 
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 enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of extremity veins provided 
on May 05, 2023. 
 
You asked the Plan to waive the copayment for the duplex scan of extremity veins. You say that it is too high 
and you cannot afford to pay more than what the insurance pays. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for the duplex scan of extremity veins. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 the duplex scan of extremity veins provided on May 05, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 5, 2023 to 
September 3, 2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 6, 2023. The NOA was not received by the Plan until September 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on August 5, 2023 to September 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc nucleus pulposus allograft. 
 
You asked the Plan to pre-approve VIA disc nucleus pulposus allograft. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says there are not enough medical 
studies to show this procedure improve the health of patients with your medical condition. 
 
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 VIA disc nucleus pulposus allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA disc nucleus pulposus allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve VIA disc nucleus pulposus allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 17, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 17, 2023.