Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom oral device (E0486). 
 
You asked the Plan to pre-approve the custom oral device. You say that you travel a lot and need this item. The 
Plan denied your request. The Plan says the statement of medical necessity submitted by the treating specialist 
clearly express that patient is continuous positive airway pressure (CPAP) tolerant and the necessity of the 
mandibular advancement device (MAD) is mainly because patient travels frequently (comfort and 
convenience).  
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the custom oral device (E0486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212), and complete denture - maxillary (D5110) provided on 
March 23, 2023. 
 
You asked the Plan to pay for the mandibular partial denture  resin base and complete denture - maxillary. 
You say that you and your family paid out of pocket for your previous dentures, so there should be no 
frequency limitation. The Plan denied your request. The Plan says your benefit for these services 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 complete denture - maxillary was exhausted on date of service March 4, 2019 and 
the mandibular partial denture  resin base was exhausted on date of service November 4, 2019. Therefore, we 
decided that the Plan does not have to pay for a mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212), and complete denture - maxillary (D5110) provided on 
March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted.  The Plan denied your request. The Plan says admission to a SNF if not medically necessary. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has shown marked improvement in their functional levels with therapy in 
the hospital as their medical condition has improved, and they would be expected to continue to improve at a 
less intensive level of care. The services they need can be provided safely in other settings, for example, a 
skilled nursing 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 this is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve the MRI of the breast.. You say that the MRI is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage at this time. 
 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 MRI of the breast. Our reviewer 
says that the requested MRI is not medically necessary. Our physician reviewer found while the enrollee has a 
positive family history there is no calculation of lifetime risk of breast cancer using either Gail risk model or 
the Tyrer-Cuzick model. In order to qualify for breast MRI these models need to show a greater than 20% 
lifetime risk. Such a calculation is not in the records. At this point the medical necessity of the requested breast 
MRI has not been established in the submitted records. 
 
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 MRI of the breast. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the breast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and mandibular 
partial denture - cast metal framework with resin denture bases (D5214) provided on March 9, 2023. 
 
You asked the Plan to pay for the complete denture - maxillary and mandibular partial denture. The Plan denied 
your request. The Plan says your benefit for the requested services 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 complete denture - maxillary was exhausted on date of service May 31, 2021, and 
the mandibular partial denture was exhausted on date of service April 7, 2022. Therefore, we decided that the 
Plan does not have to pay for a complete denture - maxillary (D5110), and mandibular partial denture - cast 
metal framework with resin denture bases (D5214) provided on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on June 13, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on June 13, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of COPD, congestive heart failure, protein calorie malnutrition and is living at home 
with weakness and functional decline. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain ceramic for tooth # 22, 23, 25 and 27. 
 
You asked the Plan to pre-approve a crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says your teeth don't have enough damage to your teeth for the procedure to be approved.  
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a review of the documentation indicates that 
teeth #'s 22, 23, 24 and 27 do not appear to have significant coronal breakdown due to caries or fracture to meet 
the criteria for coverage for crown restorations.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve crown - porcelain ceramic for tooth # 22, 23, 25 and 27.
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. The Plan denied your request. The Plan says your 
records do not show you need continued treatments and care that can only be given in a hospital setting. 
Services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that you require that are not available at 
the current health care setting being offered by the health plan. 
 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 custom fabricated abutment (D6057) and an abutment 
supported to a crown (D6059) for tooth #3 provided on December 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not know why the Plan did not cover the 
dental charges. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because implants and all related services 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 pay for a custom 
fabricated abutment (D6057) and an abutment supported to a crown (D6059) for tooth #3 provided on 
December 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0300, G0299, G0156) provided 
on January 3, 2022, to January 26, 2022.  
 
You asked the Plan to pay for home health 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 are not medically necessary. 
The record does not indicate that the services were medically necessary and medical records have yet to be 
obtained. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care 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 home health services have not been met. No supporting medical records were 
provided. Therefore, we decided that the Plan does not have to pay for the home health services (G0300, 
G0299, G0156) provided on January 3, 2022, to January 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the medical records 
provided support the need for the ambulance transport services. The Plan denied your request. The Plan says 
the service provided is not covered based on corporate medical policy criteria. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital upon discharge was not medically necessary.  
 The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) 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 ambulance services and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 14, 2023. 
 
You asked the Plan to pay for the billed codes. You say that the claim was improperly processed. The Plan 
denied your request. The Plan says the codes are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88381. This 
means there is both a professional and technical component for the CPT code(s). In this case, an appropriate 
modifier to indicate the professional component has not been billed with the CPT codes at issue. 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 88341, 88342, 88360, and 88381 billed for date of service 
February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply 
allowance (A4595) provided on September 26, 2023. 
 
You asked the Plan to pay for the TENS supply allowance. You say that the item is medically necessary. The 
Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items that are medically necessary are 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 pay for the TENS supply allowance. Our reviewer 
says that the request is within the utilization limit. Our physician reviewer found the item 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 the TENS supply allowance have been met. Therefore, we decided that the Plan 
has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply allowance (A4595) provided on 
September 26, 2023.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204, 99213), electrocardiogram (ECG) 
(93010), echocardiography (ECHO) (93306), and pre-symptom memory loop event recording (93272), 
provided on September 8, 2021, through September 9, 2021. 
 
You asked the Plan to pay for the outpatient visits, an ECG, ECHO and pre-symptom memory loop event 
recording. You say that the services should be covered. The Plan denied your request. The Plan says no 
medical records were submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient visits, an ECG, ECHO 
and pre-symptom memory loop event recording have been met. We are unable to determine medical necessity 
as no medical records were submitted for review.. Therefore, we decided that the Plan does not have to pay for 
the office visit (99204, 99213), electrocardiogram (ECG) (93010), echocardiography (ECHO) (93306), and 
pre-symptom memory loop event recording (93272), provided on September 8, 2021, through September 9, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician supervision 
(G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician supervision. You say that this is 
medically necessary. The Plan denied your request. The Plan says the records do not show that the wound has 
not shown any signs of healing for 30 days. The enrollee's blood sugar is not controlled. 
 
The Plan follows Medicare rules. 
 
   
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 hyperbaric oxygen therapy with 
physician supervision. Our reviewer says that the enrollee does not meet coverage criteria for the requested 
service. Our physician reviewer found the enrollee is noted to be a diabetic, who suffered a puncture wound to 
his foot in May 2023.  Despite magnetic resonance imaging findings at that time, gas gangrene or a necrotizing 
infection was not declared. While initial treatment was delayed, the wound has been improving. While the 
enrollee is offloading his foot, the enrollees diabetes is not well controlled. Consequently, the records do not 
indicate that the enrollee has failed standard care for treatment of his traumatic injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy with physician supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician 
supervision (G0277, 99183).