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 still has medical and therapy needs that 
cannot be met in a skilled nursing facility. The Plan denied your request. The Plan says that the enrollee does 
not meet Medicare guidelines for IRF admission.  
 
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 enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of both knee cartilages using an endoscope. 
 
You asked the Plan to pre-approve the knee arthroscopy. You say that the pain at times immobilizes you and 
often bring you to tears. You say that your walking has slowed, and you cannot take step as normal as you can 
only go one step at a time, which is causing you concern for falling because you live on the second floor. The 
Plan denied your request. The Plan says the knee arthroscopy is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that the clinical effectiveness of arthroscopic lavage and 
arthroscopic debridement for the severe osteoarthritic knee has not been verified by scientifically controlled 
studies and apart from the noncovered indications above for arthroscopic lavage and/or arthroscopic 
debridement of the osteoarthritic knee, all other indications of debridement for the subpopulation of patients 
without severe osteoarthritis of the knee who present with symptoms other than pain alone. 
 
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 knee arthroscopy. Our reviewer 
says that the knee arthroscopy is not medically necessary. Our physician reviewer found that clinical and 
effectiveness of arthroscopic lavage and arthroscopic debridement for the progressive arthrosis and relatively 
severe osteoarthritic knee has not been verified by scientifically controlled studies. Also, there is no compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the enrollee does not meet the NCD coverage criteria.  
 
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 knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the removal of both knee cartilages using an endoscope.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scans (93880, 93931, 93970) provided on April 13, 
2023. 
 
You asked the Plan to pay for duplex scans (93880, 93931, 93970). You say that the services were necessary 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for duplex scans (93880, 93931, 93970) provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with a single power 
option and power tilt. 
 
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. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
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 records do not support that the 
enrollee is at high risk for skin breakdown and is unable to perform a functional weight shift, has a history of pressure ulcers, or has had skin flap surgery. The records do not document she performs bladder self-
catheterization and is unable to transfer independently. or has increased muscle tone or spasticity. The criteria 
for coverage are not met and the requested Group 3 PWC with single power option and power tilt are not 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with a single power option and power tilt.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are resubmitting the claim for the wisdom 
tooth extraction you received. You say you have enclosed the claim image, a statement of services, a statement 
of necessity for the treatment and notes from the dentist. 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 panoramic radiographic image was exhausted on date of service June 5, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on August 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient mental health services 
provided from January 6, 2023, to October 30, 2023. 
 
You asked the Plan to waive the copayment for the mental health services. You say that nobody advised you of 
the copayment amount. 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 $20 
copayment for each individual/group therapy visit. You have been asked to pay a $260 copayment for the mental health services ($20 copayment x 13 services = $260). These items/services fall within the outpatient mental health care 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 outpatient mental health services provided from January 6, 2023, 
to October 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. Code 99291 was billed with primary diagnosis code D63.1, defined 
as erythropoietin resistant anemia. This code is not an appropriate primary diagnosis as the code has a Code 
first note indicating to code the underlying condition first. Based on this information, we decided that Medicare 
rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service March 3, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided on August 10, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the skilled nursing services. The Plan denied your request. The Plan says the 
physician is not a network provider and these services are not urgent or emergent, nor were they 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
the skilled nursing services provided on August 10, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500, 83520, and 87798 billed for date of 
service August 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that you are obligated to process specimens received. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500. The 
documentation does not show that code 87150, billed with the XU modifier, was an unusual non-overlapping 
service. Based on this information, we decided that the Medicare rules for coverage have not been met. 
 
We find that CPT code 87798 is not supported. The records show that the fecal helicobacter pylori (H. pylori) 
stool test was billed and paid for with code 87338. Neither the order form nor lab results show that 2 separate 
H. pylori tests were provided. Additionally, the claim at issue does not confirm what tests are associated with 
the unspecified test codes 87798 and 83520. 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 procedure codes 
87500, 83520, and 87798 billed for date of service August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of residual tooth roots (D7250 x 6), non-intravenous 
conscious sedation (D9248), and medicaments dispensed for home use (D9630 x 5) provided on September 22, 
2023.  

You asked the Plan to pay for the 6 additional removal of residual tooth roots, sedation services, and 5 
medicaments for home use. You say that you thought that the insurance would cover everything with dental 
services that need to be done. You say that you do not have money for the dental services. You also say that 
you would not have had these services done had you known what your share would be. The Plan denied your 
request. The Plan says 2 oral surgery procedures are covered per year. The Plan says that the frequency limit 
for oral surgery procedures has been exhausted. The Plan also says that non-intravenous conscious sedation and 
medicaments dispensed for home use are not listed as covered services. 
 
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 and oral surgery procedures are listed 
as covered, the frequency limitation has been met. Additionally, the non-intravenous conscious sedation and 
medicaments dispensed for home use are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for removal of residual tooth roots (D7250 x 6), non-intravenous conscious 
sedation (D9248), and medicaments dispensed for home use (D9630 x 5) provided on September 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pre-approve the LTACH services. You say that enrollee's needs require prolonged hospitalization and close physician monitoring. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this time because enrollee is hypotensive and tachycardic.

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 is an 81-year-old female who was admitted to the acute care hospital with acute on chronic congestive heart failure exacerbation, COPD exacerbation, and pneumonia, and complicated by encephalopathy. Recent notes describe the enrollee still with hypotension, tachycardia, respiratory distress on vent support, and with an overall poor prognosis. The enrollee appears to still be unstable and requires additional acute care services that can safely be provided at the current facility until more stable and appropriate for transfer. 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 the enrollee is not stable for transfer and as it would not be clinically advantageous. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D5214), and a complete 
maxillary denture (D5110). 
 
You asked the Plan to pay for D5214 and D5110. You say that this dental work is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial 
mandibular denture (D5214), and a complete maxillary denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve a catheter placement in coronary artery(s) for coronary angiography. The 
Plan denied your request. The Plan says the appeal is denied because the enrollee was seen for a Lexiscan 
stress single-photon emission computerized tomography (SPECT) in May 2023 showed no evidence of 
Ischemia and normal left ventricular ejection fraction (LVEF). The Plan also says the event monitor showed no 
significant arrythmias.  
 
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 catheter placement in coronary 
artery(s) for coronary angiography. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a negative 
radionuclide stress test in 2023, a normal ejection fraction on echocardiography, and negative ambulatory 
electrocardiogram monitoring. Guidelines do not support a need for invasive cardiac catheterization in this 
setting. Our reviewer found as a result, at this time cardiac catheterization would not be considered medically 
appropriate and necessary in this enrollee's 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 a catheter placement in coronary artery(s) for coronary angiography have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a catheter placement in coronary 
artery(s) for coronary angiography (93458).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ongoing treatment follow up visits, blood work, 
electrocardiogram, and genetic testing to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve ongoing treatment follow up visits, blood work, electrocardiogram, and 
genetic testing to be rendered by an OON provider. You say that due to the complexity of the case, you feel it 
is in this patient's best interest and their wants to pursue treatment with you. The Plan denied your request. The 
Plan says this request cannot be approved. The Plan also says that the patient's plan only covers healthcare 
providers who are in-network. 
 
The Plan must follow Medicare rules. Medicare rules generally allow plans to restrict enrollees to using plan 
providers as long as there are plan providers available to meet the enrollees needs. The enrollees contract with 
the Plan says that, with few exceptions, enrollees must use contract providers for care. Medicare rules also 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 ongoing treatment follow up visits, 
blood work, electrocardiogram, and genetic testing to be rendered by an OON provider. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found tertiary care after this initial consultation is not medically necessary. The patient is being started 
on a standard of care medication (Osimertinib) and follow-up blood work and visits can be completed within 
the patient's network. Our reviewer also found that in-network consultations are available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ongoing treatment follow up visits, blood work, electrocardiogram, and genetic 
testing to be rendered by an OON provider have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ongoing treatment follow up visits, blood work, electrocardiogram, and genetic testing to 
be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on August 08, 2023, to August 
16, 2023. 
 
You asked the Plan to pay for wound care services. You say that this was medically necessary and should be 
covered. Please review records and reconsider. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for wound care services provided on August 08, 2023, to August 16, 2023.