Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral images (D0220/D0230), a cone beam CT 
capture (D0364), a pulp vitality test (D0460), bitewings (D2740), and a root canal (D3320), a retreatment of a 
root canal (D3346), post removal (D2955), provided on February 13, 2023, to March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that these services should be 
covered. The Plan denied your request. The Plan says the rendered dental services have been denied 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, certain limitations apply. The record 
shows your benefit for D0220 was exhausted on February 27, 2023. The annual dental allowance amount was 
exhausted on March 7, 2023. This benefit does not include D0364, D0460, or D2955. Therefore, we decided 
that the Plan does not have to pay for additional intraoral images (D0220/D0230), a cone beam CT capture 
(D0364), a pulp vitality test (D0460), bitewings (D2740), and a root canal (D3320), a retreatment of a root 
canal (D3346), post removal (D2955), provided on February 13, 2023, to March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open implantation of cranial nerve neurostimulator 
electrode array and pulse generator (64568). 
 
You asked the Plan to pre-approve Vagus Nerve Stimulation (VNS). You say that the provider has ordered the 
VNS System to treat the enrollees severe upper limb deficit caused by ischemic strokes. The Plan denied your 
request. The Plan says medical records submitted do not document that the enrollee has been diagnosed with 
medically refractory partial onset seizures or treatment resistant depression. 
 
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 Vagus Nerve Stimulation (VNS). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that based on the medical records provided, there is no documentation that 
the VNS at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and 
effective for the enrollee. Provided records in this case do not document the enrollee has refractory epilepsy or 
resistant depression. Medicare states that if electric nerve stimulation is employed to treat motor function 
disorders, no reimbursement may be made for the stimulator or for the services related to its implantation since 
this treatment cannot be considered reasonable and necessary. Also, provided medical records and review of 
the current peer-reviewed medical literature do not document that use of the VNS device has been shown in 
controlled studies in a CMS-approved journal to result in long term health benefits in enrollees with hemiplegia 
and hemiparesis following cerebral infarction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vagus Nerve Stimulation (VNS) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an open implantation of cranial nerve neurostimulator electrode array 
and pulse generator (64568).
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says based on the available information, admission to an IRF is not reasonable 
and necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plans denial should be upheld.  The 
enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition has changed recently and 
needs acute inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's medical 
condition is stable. The PLan says the enrollee can perform bathing and dressing tasks with contact guard 
assistance. The Plan says services may 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 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the requested IRF services will provide 
significant improvement for your condition. You feel a skilled nursing facility will not meet your needs. The 
Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you 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: 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 currently meets the criteria 
for an LTACH and is stable for transfer as evidenced by clinical information. The Plan denied your request. 
The Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for 
approval. 
 
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 was admitted following a cardiac arrest while receiving chemotherapy 
and subsequently determined to have had a stroke. The record indicates that the enrollee has ongoing acute 
medical issues and still requires acute care services. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) and computed tomography 
(CT) scan (78816). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 a PET/CT scan. Our reviewer says that 
the services are medically necessary. Our physician reviewer found based upon the number of malignancies 
and the history of lung metastases the request for PET/CT is 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 a PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) and computed tomography (CT) scan (78816).  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's medical record overall  complies with the various documentation requirements for IRF 
admission. The enrollees condition is in fact complex and fragile, and there is adequate reason to expect 
participation in and benefit from IRF level services (at least 15 hours weekly) to include at minimum physical 
and occupational therapy, physician oversight of polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home, as well as avoid further 
preventable re-admissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an advanced carbon fiber foot. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a request for prosthesis with K3 foot does not meet Medicare criteria as reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records go above and beyond in demonstrating the enrollee's K3 level potential, and 
specific needs for the requested components. The plan also attempts to create a more restrictive policy in 
defining K3 level ambulation. The LCD has broad inclusive K3 criteria that describes the enrollee in this case. 
The requested items are part of the basic standard of care for all community K3 ambulators given that the 
evidence of their benefits and superiority to less sophisticated alternatives are well proven and long standing. In 
this case of this enrollee, a lesser device would not meet his functional needs, and would amount to substandard 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve a prosthetic leg with an advanced carbon fiber foot.  
 
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: 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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 
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.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335, and 81479. 
 You asked the Plan to pay for the genetic testing billed. You say that medical records were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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. 
 
The file shows that a combined cardio and pharmacogenomics test panel was provided. We looked at the file 
and Medicare rules. The medical records provided do not show that the testing was ordered due to treat a 
specific medical problem. The attestation was not provided until after the testing was provided. The attestation 
is not consistent with the medical records. Additionally, this NGS panel was not billed with a single 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 22, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 
81328, 81335, and 81479.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve echocardiography services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve echocardiography services to be provided by an OON provider. You say 
that there is an active treatment plan in progress and that it is medically appropriate that the enrollee continue 
care with the requested provider. The Plan denied your request. The Plan says that no medical need was shown 
as to why the enrollee cannot receive the needed treatment with a provider within the network. 
 
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.  
 
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 echocardiography services to be 
provided by an OON provider. Our reviewer says that the criteria for coverage of OON care have been met. 
Our physician reviewer found the records show that the enrollee has non-rheumatic aortic valve insufficiency, 
mild left ventricular (LV) dilation, normal LV systolic function, and is being worked up for elective SAVR 
(Surgical Aortic Valve Replacement) in a university center which is specialized in the field. The enrollee has undergone multiple echocardiograms all showing dynamic changes. A repeated echocardiogram before the 
final decision has been recommended by the surgery team. Repeating this study at the same location and 
having it interpreted by the same providers is essential to concentrate on the main issues at question without the 
risk of inter-operators/readers variability. Therefore, it is medically reasonable and necessary for the enrollee to 
continue care with the OON provider for the services in dispute. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON services have been met. Therefore, we decided that the Plan has to pre-
approve echocardiography services to be provided by an out-of-network (OON) provider.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on June 23,2023. 
 
You asked the Plan to pay for the billed services. You say that the records support the procedure was 
performed. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 20, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency room services provided on June 
23,2023.