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

 
We decided that the Plan does not have to pre-approve the hearing aids provided on March 21, 2023. 
 
You asked the Plan to pre-approve the hearing aids. You say that you suffer from tinnitus and sought help from 
this clinic. You say they were able to get hearing aids that dial specific white noise to help with your severe 
tinnitus. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by network providers.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-
approve the hearing aids provided on March 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs services and is diagnosed with 
Cerebral Infarction Unspecified. The Plan denied your request. The Plan says the enrollee has no daily skilled 
nurse or therapist needs. 
 
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 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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physician services. You say that you need to go to the requested Provider
because you cannot find anyone to help you and you don't know what to do. The Plan denied your request. The 
Plan says you may obtain preauthorization to a non-network provider if there is no network provider with 
appropriate training and experience to meet your particular health care needs OR the care or services are 
medically necessary OR prior written authorization was obtained from the Medical Director (Your primary 
care physician will obtain such authorization.). 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to continue skilled nursing 
facility care, including physical and occupational therapy. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for Skilled Nursing Facility. 
 
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 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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on April 20, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that you have a $2,400 hearing aid allowance. You say 
you do not know why your claim was denied. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids provided on April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ruptured breast implant removal surgery provided on March 29, 2023 
 
You asked the Plan to pay for the surgery. You say that you needed the surgical removal 
and replacement of the two silicone breast implants that have been ruptured. The Plan denied your request. The 
Plan says the provider has opted out of Medicare services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
ruptured breast implant removal surgery provided on March 29, 2023
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
27, 2023, to March 25, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services received by the enrollee should be covered 
under the Medicare Act.  The Plan denied your request. The Plan says the enrollee's condition no longer met 
criteria for continued SNF care. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pay for skilled nursing facility (SNF) care provided from February 27, 2023, to March 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system, tilt only (E1002). 
 
You asked the Plan to pre-approve the power tilt. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 power tilt. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 power tilt have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seating system, tilt only (E1002).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing, 22 or more drug class(es), including metabolite(s) if 
performed (G0483) provided on January 20, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, review of the file shows that 
exactly 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the drug testing have been met. Therefore, we decided that the Plan has to pay for the drug testing, 22 or more 
drug class(es), including metabolite(s) if performed (G0483) provided on January 20, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950 x2) provided on October 18, 2022. 
 
You asked the Plan to pay for core buildup . You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
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 core 
buildup (D2950 x2) provided on October 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87186, 87498, 87502, 87634, and 87798 provided on 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 87186, 87498, 87502, 87634, and 87798. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 87186, 87498, 87502, 87634, and 87798 by a contract provider. 
The file does not show that the plan provided notice that procedure codes 87186, 87498, 87502, 87634, and 
87798 would not be covered. Under Medicare rules, this means procedure codes 87186, 87498, 87502, 87634, 
and 87798 are considered approved by the plan. Therefore, we decided that the Plan has to pay for procedure 
codes 87186, 87498, 87502, 87634, and 87798 provided on November 28, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87591 and 87661 billed for date of 
service February 8, 2023. 
 
You asked the Plan to pay for procedure codes 87491, 87591 and 87661. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says payment for 
codes 87491, 87591 and 87661 is bundled into payment for code 87801. 
 
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, we have confirmed that codes 
87491, 87591 and 87661 are column II codes to column I code 87801. These services have not been billed with 
an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87491, 87591 and 
87661 billed for date of service February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration and soft tissue graft procedures (D4278, D4265, D4277, D4620) provided on April 6, 2023. 
 
You asked the Plan to pay 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for biologic 
materials to aid in soft and osseous tissue regeneration and soft tissue graft procedures (D4278, D4265, D4277, 
D4620) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0367), guided tissue regeneration 
(D4266), the primary closure of a sinus perforation (D7261), the collection and application of blood (D7921), 
and the bone replacement graft (D7953) for tooth #15, #17, #21, #25, #26, #27, #31, and #32. 
 
You asked the Plan to pre-approve the dental services. You say that your doctor says the procedures are 
medically necessary and will help your healing process. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because the cone beam, guided tissue regeneration, the primary 
closure of a sinus perforation, the collection and application of blood, and the bone replacement graft 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 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 
cone beam (D0367), guided tissue regeneration (D4266), the primary closure of a sinus perforation (D7261), 
the collection and application of blood (D7921), and the bone replacement graft (D7953) for tooth #15, #17, 
#21, #25, #26, #27, #31, and #32.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 28, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
and 81334.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says the enrollee has no 
genetic condition or syndrome which might make them high risk for upper gastrointestinal cancers. The Plan 
also says there are no qualifying criteria in this enrollee's history or presenting complaints which would 
indicate that they are suitable for a screening EGD. 
 
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 an EGD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care guideline criteria denotes the following as medically necessary criteria for a 
post-bariatric surgical evaluation by EGD: nausea or vomiting, abdominal pain, post-operative 
Gastroesophageal Reflux Disease (GERD), dumping syndrome, diarrhea, nutritional deficiencies, stenosis, 
bezoar, fistulas, leaks, upper gastrointestinal tract bleeding. The enrollee takes nutritional supplements, does 
not meet the criteria cited above, and recent weight gain is likely due to diet indiscretion as documented per the 
July 17, 2023, charting. At the enrollee's current weight and body habitus, the risks of endoscopic and sedation 
complications are significant. Our physician reviewer also found that routine tandem performance of a 
screening EGD in addition to their high-risk colonoscopy screening is at this time neither medically appropriate 
nor necessary given the absence in the enrollee's case of indications and the provided clinicals. 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).