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 is below baseline, requiring assistance 
with inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements. Services needed may be provided safely in 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 80299, 85025, 85610, and 85730 
provided on September 11, 2021. 
 
You asked the Plan to pay for procedure codes 80053, 80299, 85025, 85610, and 85730. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 80053, 80299, 85025, 85610, and 85730 are packaged services due to being billed on 
the same claim as code 99285, which has a status indicator of V. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 80053, 80299, 85025, 85610, and 85730 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 80053, 80299, 85025, 85610, and 
85730 provided on September 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on July 5, 2022. 
 You asked the Plan to pay for the air ambulance transport and air mileage. You say that  the air transport was 
medically necessary as the enrollee needed higher level of care and services were not available within the 
geographic area. The Plan denied your request. The Plan says the enrollee could have been safely transported 
via ground ambulance to the nearest hospital that could provide the services that the enrollee required. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport and air mileage. 
Our reviewer says that the air ambulance services were not medically necessary. Our physician reviewer found 
the enrollee was evaluated for left-side facial-droop, which resolved while in the emergency department. While 
transfer for neurologic evaluation may have been warranted, the use of air ambulance does not appear to have 
been medically necessary. The enrollee could have safely transported by a ground ambulance without 
endangering the enrollee's condition. 
 
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 air ambulance transport and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one way 
and air mileage provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite - one surface, anterior (D2330), 
complete denture - maxillary (D5110), reline complete maxillary denture (indirect) (D5750), reline mandibular 
partial denture (indirect) (D5761), and mandibular partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services represented by codes D2330, D5110, D5750, D5761 and 
D5214. You say that you did use an in-network dentist but he decided to refuse you. You also say that the plans 
representative tried to find you another in-network dentist but was unsuccessful. The Plan says that on 
November 1 you were provided the name of two in-network oral surgeons.  The services you are appealing are done by a general dentist. The Plan denied your request. The Plan says 
dental services from an out-of-network provider are not covered by your supplemental benefits.  
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a resin-
based composite - one surface, anterior (D2330), complete denture - maxillary (D5110), reline complete 
maxillary denture (indirect) (D5750), reline mandibular partial denture (indirect) (D5761), and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom abutment (D6057) and the abutment 
supported to crown (D6059) for tooth #3. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services and would like the Plan to cover them. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the custom abutment and the abutment supported to crown 
are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
custom abutment (D6057) and the abutment supported to crown (D6059) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes R0075, 99204, 74230, 74240, 72040, 
70100, and 70310 provided on February 1, 2023.  
You asked the Plan to pay for procedure codes R0075, 99204, 74230, 74240, 72040, 70100, and 70310. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. Medicare rules also say that the technical component of a 
portable x-ray service during the course of a Medicare-covered stay in a skilled nursing facility (SNF), 
representing the procedure itself, including any associated transportation and setup costs, would be subject to 
consolidated billing (the SNF bundling requirement for services furnished to the SNFs Part A residents), and 
must be included on the SNFs Part A bill for the residents covered stay rather than being billed separately 
under Part B. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed services (99204, 74230, 74240, 72040, 70100, and 70310) have not been met. The 
documentation supports that the enrollee was at a skilled nursing facility setting on the date of service. As such, 
the use of the office POS code is not appropriate. Additionally, procedure code R0075 is not covered. This 
service was provided to a SNF resident and must be billed on the SNF bill.  Therefore, we decided that the Plan 
does not have to pay for procedure codes R0075, 99204, 74230, 74240, 72040, 70100, and 70310 provided on 
February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065 
x2). 
 
You asked the Plan to pre-approve 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 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 the requested item or service was exhausted under the Plans authorization 0045692270 
from August 15, 2023, through February 14, 2024. Therefore, we decided that the Plan does not have to pre-
approve implant supported porcelain/ceramic crowns (D6065 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan and 
computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 the PET/CT scan. Our reviewer says 
that the PET/CT scan is not medically necessary. Our physician reviewer found based on the records received 
the enrollee does not meet the criteria for coverage for the requested services. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan and computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft, collection and application of 
autologous blood concentrate, therapeutic parenteral injection (D9612, D7921, D4263). 
 
You asked the Plan to pre-approve 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 the services denied correctly as they do 
not fall within your dental benefits. 
 
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 pre-approve a 
bone replacement graft, collection and application of autologous blood concentrate, therapeutic parenteral 
injection (D9612, D7921, D4263).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda 
 
You asked the Plan to pre-approve the drug. You say that the request is urgent and time sensitive as a delay in 
treatment may cause disease progression and rapid deterioration. The Plan denied your request. The Plan says 
that Keytruda 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 the drug. Our reviewer says that 
Keytruda is medically necessary. Our physician reviewer found that the requested use of Keytruda is not FDA-
approved. However, Keytruda is supported by one of the major drug compendia and by clinical research. 
Keytruda is also safe and effective and otherwise 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), endosteal 
implant (D6010), bone graft at time of implant placement (D6104) and bone replacement graft for ridge 
preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered under the Plan's dental benefits. 
 
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 pre-approve the 
guided tissue regeneration (D4266), endosteal implant (D6010), bone graft at time of implant placement 
(D6104) and bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre reader and sensor.  
You asked the Plan to pre-approve the FreeStyle Libre reader and sensor. You say that the Libre has helped the 
enrollee with lifestyle changes/improvements that are important to control their diabetes. You also say that this 
will prevent or decrease risk of diabetes mellitus complications. The Plan denied your request. The Plan says 
the enrollee does not qualify for a therapeutic CGM because medical records show they are  not actively on 
insulin and has not met the definition of hypoglycemic. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre reader and sensor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre reader and sensor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced imaging of the brain (codes 78830 and 
A9584) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the advanced imaging of the brain. You say that the enrollee requires this 
care. The Plan denied your request. The Plan says the services are not emergent/urgent and are available within 
the enrollee's network. The provider who requested the testing was not aware the testing was available in-
network. The Plan also says the enrollee has an authorization for the testing within the Plan's network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
advanced imaging of the brain (codes 78830 and A9584) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1830). 
 
You asked the Plan to pay for the knee orthosis. You say that the item should be covered. The Plan denied your 
request. The Plan says the medical records submitted by providers does not contain a signed valid order and 
proof of delivery for this item. 
 
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 a valid physician order or proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. 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 knee orthosis (L1830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that the test provides targeted non-opioid treatments. 
The Plan denied your request. The Plan says an incorrect place of service was billed. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 28, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still needs the services until he gets 
better. The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February 9, 
2023, to July 29, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) services.