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

 
We decided that the Plan does not have to pay for the dental services (D7286 and D7250) on November 8, 
2022. 
 
You asked the Plan to pay for the dental services (D7286 and D7250). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the 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 the dental 
services (D7286 and D7250) on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GuardantReveal (81479) provided on October 23, 2022. 
 
You asked the Plan to pay for GuardantReveal. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of GuardantReveal have not been met. Therefore, we decided that the Plan does 
not have to pay for GuardantReveal (81479) provided on October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
receive the care needed to rebuild your strength. The Plan denied your request. The Plan says you do not meet 
the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the enrollee requires treatment monthly for recurrent 
lung cancer. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
requested use of Opdivo is medically necessary. Our physician reviewer found requested use is indicated for 
enrollee's diagnosis. Therefore, the reviewer found that the requested use of Opdivo is medically reasonable 
and 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 Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986). 
 
You asked the Plan to pre-approve a manual wheelchair accessory. You say that the requested accessory is 
medically necessary. The Plan denied your request. The Plan says the notes show that you are not alone in your 
home, and you have family to assist with mobility when upper and lower extremity movement fails to meet 
your needs. Because family is readily available to assist, that the power assist for the requested wheelchair 
would add value but does not meet the Medicare criteria for approval. 
 
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 manual wheelchair accessory. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have strength to manage a manual wheelchair but fatigues and both 
therapy evaluations agree. You have inconsistent capacity to manage a push rim power activated chair. You are 
never alone, and you have consistent help with ADLs. Per NCD 280.3, the record indicates you have caregivers 
available when you fatigue. The frequency of your needs is unclear and care giver burden is not addressed. 
Medical necessity for the power activated push rim is not established. 
 
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 manual wheelchair accessory have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a push-rim activated power assist system (E0986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540, and 83550) 
related to end-stage renal disease (ESRD) provided on December 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate.  
 No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (codes 82728, 83540, and 83550) related to end-stage renal disease (ESRD) provided on 
December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve microprocessor foot. You say that the microprocessor foot is medically 
necessary. The Plan denied your request. The Plan says the request for microprocessor foot does not meet 
Medicare criteria as reasonable and 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 microprocessor foot. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that you require a microprocessor foot given 
your functional activities, history of using a cane on uneven terrain in the past, and history of and history of 
finding your microprocessor foot too heavy in the past. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microprocessor foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source (L5973).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you require LTACH services and are not 
receiving adequate care at the skilled nursing facility, resulting in your return to the hospital. 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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says that the SNF services requested do not meet the 
requirements for approval. 
 
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 care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is on a ventilator and has tube feedings with at least 25% of their 
nutrition. Per chapter 8 of the Medicare Benefit Policy Manual, the enrollee has daily skilled nursing needs. 
 
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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99291) provided on November 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is 
included in the global surgery payment for code 93456. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that payment for the requested services is included in the global 
surgery payment for code 93456. However, the Plan has not provided documentation showing that code 93456 
was billed on the same date of service as code 99291. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (99291) provided on 
November 14, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertebroplasty. 
 
You asked the Plan to pre-approve a vertebroplasty. You say that the enrollee has multiple deformities on her 
magnetic resonance imaging (MRI) showing short T1 inversion (STIR) changes due to her acute compression 
fractures. You say that this shows the enrollee could have significant improvement of her pain with 
vertebroplasty. You say that the enrollee is in significant pain related to these fractures and has lost her ability 
to complete many activities of daily living. You say that the enrollee can walk or stand only with great pain and 
that her quality of life has drastically decreased. The Plan denied your request. The Plan says the requested 
surgery is only supported for new fractures, and the enrollee's fracture is more than 6 weeks old. The Plan says 
that the requested procedure is recommended for no more than 3 levels, and the enrollee's doctor is asking for 6 
levels. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty is only covered when the 
enrollee has acute or subacute osteoporotic VCF documented by recent advanced imaging.  
 
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 vertebroplasty. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found there is no imaging study showing 
that the fractures are less than 6-weeks old. 
 
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 vertebroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vertebroplasty.
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 it is medically necessary for the enrollee to go to 
inpatient rehabilitation. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for approval. The enrollee can safely receive the services you need in other settings, for example. 
 
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 clinical documentation shows that the enrollee has complex functional 
impairments and active medical comorbidities. However, the evaluating therapist (occupational therapist) 
recommends ongoing therapy in a skilled nursing facility. Additionally, documentation does not show that the 
enrollee would tolerate an intensive therapy regimen (poor baseline functional status and tolerance of therapy 
evaluations). Thus, IRF criteria is not 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 1 additional occupational therapy visit. 
 
You asked the Plan to pre-approve an occupational therapy visit. You say that the enrollee still requires 
occupational therapy services due to significant pain in the right shoulder and right arm which is affecting their 
activities of daily living. The Plan denied your request. The Plan says 1 additional occupational therapy visit is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 occupational therapy visit. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has chronic impairment from a 
stroke they previously had 6 years ago. The enrollee has residual weakness which has shown little change in 
function since January 2023. Although the enrollee has a home exercise program, they are not expected to 
make additional neurological gains. Therefore, the enrollee does not require additional input from a skilled 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy visit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 1 additional occupational therapy visit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) provided on October 22, 2022. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal (81479) provided on October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek branded diabetic testing supplies. 
 
You asked the Plan to pre-approve diabetic testing supplies. You say that the requested diabetic testing supplies 
are a necessity for your care. The Plan denied your request. The Plan says only the preferred brand products 
listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear, accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic testing supplies. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek 
branded diabetic testing supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57282 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 57282. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 57282 is bundled into 
payment for code 58260. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 57282 
is a column II code to column I code 58260. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 57282 billed for date of service September 30, 
2022.