Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behaviorial health treatment. 
 
You asked the Plan to pre-approve inpatient behaviorial health treatment. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 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 behaviorial health treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided for the admission of this enrollee does not meet the criteria for October 9, 2023 
forward as this enrollee was not shown to be a danger to herself or others. There were no delusions, auditory or 
visual hallucinations noted. She was cooperative/compliant with treatment while not showing any threats the 
safety. 
 
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 behaviorial health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behaviorial health treatment.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the non-microprocessor hydraulic knee (L5814, L5845, L5850) 
and flex-walk style foot with axial rotation unit and vertical shock reducing pylon (L5981, L5984, L5988).  
 
You asked the Plan to pre-approve the non-microprocessor hydraulic knee and flex-walk style foot with axial 
rotation unit and vertical shock reducing pylon. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that these items exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 non-microprocessor hydraulic knee 
and flex-walk style foot with axial rotation unit and vertical shock reducing pylon. Our reviewer says that the 
items are medically necessary. Our physician reviewer found the medical records go above and beyond in 
satisfying Medicare policy by demonstrating this enrollee has K3 functional level potential and has specific 
needs for the requested components. 
 
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 non-microprocessor hydraulic knee and flex-walk style foot with axial 
rotation unit and vertical shock reducing pylon have been met. Therefore, we decided that the Plan has to pre-
approve the non-microprocessor hydraulic knee (L5814, L5845, L5850) and flex-walk style foot with axial 
rotation unit and vertical shock reducing pylon (L5981, L5984, L5988).   
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has a history of dementia and anxiety, and 
the requested examination is not appropriate to diagnose this condition. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was noted to have an 
abnormal Montreal Cognitive Assessment (MOCA) score. However, the records only suggested the possibility 
of AD or alternatively, poor performance due to anxiety. In as much the base requirement of the NCD for this 
service would not be met as the enrollee is not noted to meet diagnostic criteria for both AD and FTD. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET/CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia injection services provided on January 3, 2023, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the Prolia injection services provided OON. You say that you went to this clinic 
and asked if they needed your new insurance card, but they advised you that it wasn't necessary and that the 
services were already authorized. You say that you understand that the healthcare persons you deal with are 
overworked and that you don't blame anyone, but that you would hope your new insurance company would 
honor this claim. The Plan denied your request. The Plan says these OON services were not emergent and were 
not pre-authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the OON 
service at issue. We found no exception that would require the Plan to pay for these services from an OON 
provider. Therefore, we decided that the Plan does not have to pay for Prolia injection services provided on 
January 3, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. You have had extensive 
prior therapy and has been provided ample therapy to be well versed in a home exercise program. The 
requested additional therapy sessions are not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty (D7310) and the removal of torus 
palatinus (D7472). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary 
so you can get dentures. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the alveoloplasty and the removal of torus palatinus 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 the 
alveoloplasty (D7310) and the removal of torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D0220, D3330) provided on June 5, 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 charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plan's cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D0220, D3330) provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on June 9, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99232, 99239) provided on February 15, 2023 
to February 16, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not supported in the records provided. 
 
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 definitions of codes 99232, & 99239 are subsequent hospital care and 
hospital inpatient or observation discharge management. 
 
We find that CPT codes 99232, & 99239 are not supported in the medical record. Specifically, the records 
provided did not include any evaluation and management note for billed date of service February 16, 2023. Based on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient care (99232, 99239) provided on 
February 15, 2023 to February 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0299). 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee has been educated on his disease process and medications. No medical notes from the 
enrollee's treating physician are provided documenting an order or need for additional skilled nursing services. 
Records do not document the need for intravenous medications, new tube feeding or ostomy care or complex 
wound care. The enrollee appears to have improved with therapy to the point of being able to manage 
ambulation, transfers and most activities of daily living at the supervision level. After the previously provided 
therapy treatments, records do not support that the complexity of the enrollee's conditions are such that the 
skills of a professional therapist are required to achieve further improvement in the enrollee's symptoms or 
functional status. Further utilization of the home exercise program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade with harness and 
electronic connection for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have adequate strength to manage the standard controls for the approved power drives. The requested expandable 
controller and associated electronics are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller upgrade with harness and electronic connection for a power 
wheelchair (PWC).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We 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 home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled occupational therapy needs. As such, the requested home health services are not medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000-59-26 rendered on April 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
operative report describes a spinal procedure performed with fluoroscopy, in this case, the fluoroscopy 
interpretation would be inclusive to the fluoroscopy used during the procedure. Therefore, this procedure code 
and appended modifier 59 distinct procedural service cannot be verified. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76000-59-26 rendered on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 3, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare 
benefit and are not covered. 
 
We looked at the file and Medicare rules. The testing in this case was provided for screening purposed, which 
is not covered per LCA A58918. Additionally, the panel was billed with several codes, and not one code as 
required. Based on this information, we decided that Medicare rules for coverage of the panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab panel provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), and placement of 
intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) provided on March 
29, 2023. 

You asked the Plan to pay for the panoramic radiographic image and the placement of intra-socket biological 
dressing. You say that the endodontist could not save the tooth and you were told it had to be extracted. The 
Plan denied your request. The Plan says your benefit for the panoramic radiographic image has already been 
exhausted. The Plan also says the placement of intra-socket biological dressing is not a covered expense under 
your dental 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 placement of intra-socket 
biological dressing is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per 
site (D7922) provided on March 29, 2023 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service March 17, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on March 29, 2023.