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 meets IRF criteria and is reasonably 
expected to participate in and benefit from 15 hours of therapy a week. The Plan denied your request. The Plan 
says the request 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 doctors feel this is the best place for the enrollee. 
The Plan denied your request. The Plan says the request 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 30, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 30, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 30, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 30, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 30, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 30, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 30, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve black neoprene impact guards (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested item is not medical in nature and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve black neoprene impact guards (K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for deluxe frames (V2025), bifocal lenses (V2200) and scratch 
resistant lenses (V2760) provided on July 3, 2023. 
 
You asked the Plan to pay more for deluxe frames (V2025), bifocal lenses (V2200) and scratch resistant lenses 
(V2760). You say that your explanation of benefits (EOB) does not reflect that you owe $18.20. You reached 
out to the vision Plan and were told they would request a revised explanation of benefits to verify what you 
actually owe. You also say you were told this was covered by the Plan. The Plan denied your request. The Plan 
says that this was not denied and processed correctly according to the 2023 benefit plan design. 
 
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. We find that the EOC clearly states that the Plan will pay up to $100 for 
eyewear. The EOC also clearly states that there is no copayment for lens upgrades. The records submitted 
clearly shows that the Plan was billed exactly $100 for the eyeglasses, and the vision Plan shows they did not 
pay the full $100. There are no records that show there is an amount owed above $100. The Plan failed to 
submit any documents that verify that the enrollee is actually liable for any amount toward the eyeglasses. 
Therefore, we decided that the Plan has to pay more for deluxe frames (V2025), bifocal lenses (V2200) and 
scratch resistant lenses (V2760) provided on July 3, 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: 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 (L5973). 
 
You asked the Plan to pre-approve a microprocessor foot. You say that the prosthetic is medically necessary. 
The Plan denied your request. The Plan says the request for a K3 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 a 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 enrollee has been using a mechanical foot since her amputation. Her current 
activities can safely and effectively be met with another mechanical foot. The L5973 exceeds the enrollee's 
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 a 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 (L5973).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865) and semi-
precision attachment (D6192). 
 
You asked the Plan to pre-approve a complete mandibular overdenture (D5865) and semi-precision attachment 
(D6192). You say that you do not have teeth and you need to eat. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
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 pre-approve a 
complete mandibular overdenture (D5865) and semi-precision attachment (D6192).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 7, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says these is a more appropriate panel code that should be used which is 81479. 
 
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, the CPT Code Manual definition of code 81226 is CYP2D6 (cytochrome P450, family 2, 
subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN). The CPT Code Manual definition of code 81240 is F2 
(prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant. The 
CPT Code Manual definition of code 81241 is F5 (coagulation factor V) (eg, hereditary hypercoagulability) 
gene analysis, Leiden variant. The CPT Code Manual definition of code 81328 is SLCO1B1 (solute carrier 
organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) 
(eg, *5). 
 
We asked our coder 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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found when multiple molecular genes are performed, a more appropriate 
code would be reported for services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that it is not medically necessary. 
 
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 has not gathered the medical records. Therefore, we decided that the 
Plan has to pre-approve acupuncture 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluations, crowns, and core 
buildup (D2740, D2950, D0150) provided on March 23, 2023. 
 
You asked the Plan to pay more for 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 23, 2023. 
Therefore, we decided that the Plan does not have to pay more for comprehensive oral evaluations, crowns, and 
core buildup (D2740, D2950, D0150) provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 31, 2023, billed with 
codes 87481, 87640, 87798, 87652, and 87799. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing is covered and payable. 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 urinary tract infection panel test was provided. We looked at the file and Medicare rules. 
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 July 31, 2023, billed with codes 87481, 87640, 87798, 
87652, and 87799.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer nasal airway remodeling with radiofrequency 
procedure. 
 
You asked the Plan to pre-approve VivAer nasal airway remodeling with radiofrequency procedure. You say 
that you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is 
not medically 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 VivAer nasal airway remodeling with 
radiofrequency procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has 
recurrent sinusitis. There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not 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 VivAer nasal airway remodeling with radiofrequency procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VivAer nasal airway remodeling with 
radiofrequency procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81314, 81345, and 
81272 for date of service December 5, 2022. 
 
You asked the Plan to pay for the laboratory services billed with codes 81314, 81345, and 81272. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with codes 81314, 81345, and 81272 have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services billed with codes 81314, 81345, and 81272 for date of service December 
5, 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach the notes do not show that the enrollee must have 
an intensive therapy program (3 hours a day, at least 5 days a week) in order 
to improve self-care functioning. The enrollee's medical and therapy needs could be met in a skilled nursing 
unit.   
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's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires either low blood sugars or insulin use. This enrollee is not noted to have low blood sugars, although 
the enrollee is using a medication Glipizide that can cause low blood sugars and is not using insulin. Although 
a CGM may help this enrollee, the coverage criteria are 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).