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

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the application of 
fluoride (D1206), bitewings (D0274), a crown (D2740), the periodontal scaling and root planing (D4341), the 
periodontal maintenance (D4910), the gingival irrigation (D4921), the medicaments (D9630), an unspecified 
adjunctive procedure (D9999) and to pay more for the lower partial denture (D5214) provided on September 
11, 2021, January 26, 2022, April 6, 2022, April 26, 2022, and September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for the dental 
services that you paid for. The Plan denied your request. The Plan says your dental maximum benefit for the 
year of 2021 and 2022 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 the Plan paid $327 for dental services on September 8, 2021. On September 11, 2021, the Plan paid 
$273 for dental services. For the year of 2021 the Plan paid $600 ($327 paid + $273 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2021 was exhausted on the date of service of 
September 11, 2021. The record shows the Plan paid $675 for dental services on January 26, 2022; therefore, 
your annual dental maximum benefit for the year of 2022 was exhausted on the date of service of January 26, 
2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the 
application of fluoride (D1206), bitewings (D0274), a crown (D2740), the periodontal scaling and root planing 
(D4341), the periodontal maintenance (D4910), the gingival irrigation (D4921), the medicaments (D9630), an 
unspecified adjunctive procedure (D9999) and to pay more for the lower partial denture (D5214) provided on 
September 11, 2021, January 26, 2022, April 6, 2022, April 26, 2022, and September 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 19, 2022, to 
September 6, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted several times. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 20, 2022. The NOA was not received by the Plan until December 8, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 19, 2022, to September 6, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the thorax (71270). 
 
You asked the Plan to pre-approve a CT of the thorax. The Plan denied your request. The Plan says that the 
records do not show that results of a thorough workup failed to reveal the cause of the enrollee's weight loss. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the thorax. Our reviewer says 
that this request is medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has had a recent unexplained 30-pound weight loss. Thyroid stimulating hormone and other labs have 
been normal with the exception of the Hemoglobin A1-C which is elevated. Colonoscopy was normal. Our 
reviewer found that the request for a CT of the chest is reasonable due to the weight loss.  A chest film, even if 
normal would not have precluded the need for the requested chest CT. Our physician reviewer also found that 
this exam should be approved. 
 
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 CT of the thorax have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) of the thorax (71270).  
 
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 FreeStyle Libre 2 sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. You say that you are taking weekly injections of 
Mounjaro and badly need the FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria and there is a lack of extenuating circumstances. 
 
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 a FreeStyle Libre 2 sensor. Our 
reviewer says that you do not meet the criteria for coverage. Our physician reviewer found you are on a 
medication for pre-diabetes mellitus that does not cause low blood glucoses, and you are not having low blood 
glucoses. Our reviewer found that you are not using insulin. Our physician reviewer also found that we are not 
told why a fingerstick meter would not suffice for you at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Specifically, the documentation does not 
show that you use insulin or have a history of problematic hypoglycemia. Based on this information, we 
decided that Medicare rules for coverage of a FreeStyle Libre 2 sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that the care and treatment are well within 
community standards of care and was reasonable and necessary and provided in the most appropriate setting. 
The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 an inpatient admission. Our reviewer 
says that the documentation supports that the criteria for an inpatient admission are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have been met. Therefore, we decided that the Plan has 
to pre-approve an inpatient admission.  
 
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 the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the documentation indicates 
the presence of non-vertebrogenic pathology that can explain the source of the enrollee's pain. 
 
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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause of the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (U0004, U0005, 99001) provided 
January 11, 2022, to April 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that your claims clearinghouse shows that the 
original claim submission date was prior to the timely filing deadline. The Plan denied your request. The Plan 
says the claim was submitted after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 27, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (U0004, U0005, 99001) provided January 
11, 2022, to April 16, 2022.
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 the medical records support the medical necessity for 
IRF admission. The Plan denied your request. The Plan says the services are not all met, IRF cannot be covered 
by Medicare and the Plan.  
 
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that they would meet criteria for admission to an acute inpatient rehabilitation facility. There 
is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain functional status. The enrollee can receive further care 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 10, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting a redetermination of 
the denial and have enclosed documentation to substantiate the claim. 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 
March 10, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81238.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator (E0466) is 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
home ventilator (E0466). 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator (E0466). Our physician reviewer found the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was ordered ventilator settings in the average volume-assured pressure 
support (AVAPS) mode. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with AVAPS capability and failure of such a device has not been 
documented. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 83520 is: Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, there is no indication of which tests are described by these "not otherwise specified" codes. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of current existing pressure 
ulcers or a myocutaneous flap. 
 
The Plan follows Medicare rules. Medicare rules say that when the stated coverage criteria for a group 2 
mattress or bed are not met, a claim will be denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a powered pressure reducing air 
mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no 
documentation of current existing pressure ulcers or a myocutaneous flap. 
 
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 powered pressure reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided March 8, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the evidence supporting the 
use of Cxbladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says this testing is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The CX Bladder panel remains unproven at this time. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided 
March 8, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0318 billed for date of service April 24, 2023. 
 
You asked the Plan to pay for procedure code G0318. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that payment for procedure code G0318 is bundled into 
payment for code 93350. 
 
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. Specifically, the Plan has not provided any evidence, rules or records to 
demonstrate that codes G0318 and 93350 have a bundled relationship, or that denying the more comprehensive 
code would be appropriate. It is the Plan's responsibility to support its denial with evidence. In this case, the 
Plan has not supported its denial, so we must find in your favor. Therefore, we decided that the Plan has to pay 
for procedure code G0318 billed for date of service April 24, 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.