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

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided on July 5, 2023. 
 
You asked the Plan to pay for the endodontic therapy, molar tooth. You say that you had a root canal and your 
coverage was nothing. You also say that this year and last year you had a greater amount of dental expenses 
than normal. The Plan denied your request. The Plan says your benefit for the requested service $750 dollar 
limit was met. 
 
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 dental service was exhausted on dates of service February 16, 2023, 
March 16, 2023, March 17, 2023, March 28, 2023 and April 14, 2023. Therefore, we decided that the Plan does 
not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on July 
5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 27, 2023, billed with 
evaluation and management (EM) code 99214-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99214-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that there is no examination note for the 
date of service in question. It cannot be verified that this procedure was performed as billed. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 27, 2023, billed with evaluation and 
management (EM) code 99214-25.
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 
June 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that you are obligated to process the specimen 
received. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the medical documentation. 
 
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 looked at the file and Medicare rules. We find that 4 units of code 83520 and 1 unit of 87798 is not 
supported. There are more applicable codes available for the anti-gliadin, anti-TTG, and bile acid testing. The 
appeal states that code 87798 was billed for Helicobacter pylori testing. However, this test was billed and paid 
for under code 87338. Additionally, the records provided do not support that the results of the testing would 
impact clinical management. Testing merely on the basis of a diagnosis code is not sufficient evidence for 
coverage. This testing is not covered for screening purposes. Based on this information, we decided that the 
Medicare rules for coverage 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 June 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not have any of the qualifying 
conditions. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found While the patient has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. Therefore, the reviewer found that the requested ILR 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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollees admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the LTACH services are not medically 
necessary, and the enrollee's needs can be met at 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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: 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 continued SNF services are medically necessary.  
The Plan denied your request. The Plan says the request for continued SNF services does not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0482) provided on May 16, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the code reported does not reflect the number of 
classes tested in this case. Another code would describe the services provided more accurately. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that drugs 
from more than 21 classes were tested in this case. Another code would be more appropriate for the services 
provided. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482) provided on 
May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing. 
 
You asked the Plan to pay for the requested testing. The Plan denied your request. The Plan says the test is not 
a covered benefit. 
 
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. 
 
 The medical documentation shows that an Alpha-Globulin Common Mutation Analysis was requested. We 
looked at the file and Medicare rules. After MolDX assessment, it was determined that this test did not 
demonstrate clinical utility at a level that meets the Medicare reasonable and necessary requirement. Based on 
this information, we decided that Medicare rules for coverage of the requested testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says that LTACH care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has been stabilized to the point where hospitalization at an acute care short term 
hospital is no longer necessary. However, the patient is not stable to be placed in a skilled nursing facility 
(SNF). The requested LTACH services are medically necessary, reasonable, and appropriate. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Infed and Venofer before it will approve 
Injectafer. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Injectafer. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not show that 
these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
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 need the SNF services to regain full mobility. 
The Plan denied your request. The Plan says you do not meet the requirements for SNF services. 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 an 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on July 
14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told you needed the x-ray, so you 
should not have to pay the billed amount. 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. This benefit includes the 
requested panoramic radiographic image (D0330) but has a limit of one D0330 or D0701 every three years. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received D0330 on date of service February 20, 2023. Therefore, this benefit was exhausted as of 
July 14, 2023. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image 
(D0330) provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 08, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on June 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and a limited oral evaluation - problem focused (D0140) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider by your 
dentist. You also say that they needed to take x-rays and examination of your teeth so you are requesting some 
reimbursement. 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 requested services was exhausted on date of service May 16, 2023. Therefore, we 
decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and a 
limited oral evaluation - problem focused (D0140) provided on July 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) and 
routine disposable supplies (A0398) provided on June 2, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998) and routine disposable 
supplies (A0398). You say that you passed out in church, and you do not know who called the ambulance. You 
also say that you were coherent before the rescue squad arrived. The Plan denied your request. The Plan says 
the available information shows that you were evaluated. The Plan also says you declined transport to the 
emergency room. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on June 2, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) and routine disposable supplies (A0398) provided on June 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on June 12, 2023. 
 
You asked the Plan to pay for non-emergency ambulance transport (A0428) and ground mileage (A0425) . You 
say that you transported the enrollee 679 miles from her residence to a scheduled doctor's appointment for knee 
pain. The Plan denied your request. The Plan says they cover professional ambulance service for emergency 
transport only.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergency ambulance transport (A0428) and ground mileage (A0425)  have not been met. 
Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transport (A0428) and 
ground mileage (A0425) provided on June 12, 2023.