Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for a crown (D2750) for tooth #15. We decided that the Plan does 
not have to waive the coinsurance for a crown (D2750) for tooth #15.  
 
You asked the Plan to pay more for a crown (D2750) for tooth #15 provided on June 15, 2023. You say that the 
Plan only covered a portion of the crown. The Plan says that your annual dental maximum benefit for the year 
has already been exhausted. 
 
We decided that the Plan has to pay more for a crown (D2750) for tooth #15.  
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your annual dental maximum benefit for the year was 
previously exhausted. Therefore, we decided that the Plan has to pay more for a crown (D2750) for tooth #15.  
 
We also decided that the Plan does not have to waive the coinsurance for a crown (D2750) for tooth #15. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for a crown. 
 
You have been asked to pay a 50% coinsurance for a crown. This item/service falls within the covered dental 
services chart benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. 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 crown (D2750) for tooth #15. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health specimen collection services for laboratory 
testing. 
 You asked the Plan to pre-approve home health specimen collection services. You say that these services are 
medically necessary for your care. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage of the requested services. 
 
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 specimen collection 
services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found that the clinical documentation does not show any specified coverable service under Medicare 
without home health skilled nursing; therefore, the requested services 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 home health specimen collection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health specimen collection services for laboratory 
testing.
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 IRF services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet requirements for an IRF 
admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute 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, and 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 the need for an IRF admission. The enrollee 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 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 Cala Trio device (K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 Cala Trio device. Our reviewer says 
that the requested Cala Trio device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that this device is effective for the 
enrollee's tremor. Therefore, the reviewer found that the requested Cala Trio device 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 a Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837, 90853) provided on 
July 12, 2023. 
 
You asked the Plan to pay for outpatient mental health services (90837, 90853). You say that the services at 
issue were a necessity for the enrollees care. 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 outpatient mental health 
services (90837, 90853) provided on July 12, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 You asked the Plan to pre-approve Renflexis. You say that this is the preferred medication for the hospital. The 
Plan denied your request. The Plan says the enrollee has not failed the preferred drugs.  
 
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 Renflexis. Our physician reviewer 
found that the enrollee has a diagnosis of Crohn's disease. The Plan requires a trial of one of Remicade, 
infliximab, Inflectra, or Simponi Aria; and Stelara before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for this 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
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 Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. 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 enrollee does not meet Medicare coverage criteria for an IRF admission. The 
enrollee does not need the intensity of therapies in the IRF. An IRF admission is not medically necessary based 
on the enrollee's medical stability and lack of acute rehabilitation nursing needs. The enrollee needs routine 
physical and occupational therapy. The enrollees rehabilitation needs can be met at a lower intensity and 
alternate setting such as in a skilled nursing facility.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mohs surgery and related services (17311 x 2, 12053, 
12042) provided on April 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the surgical services. You say that the provider's office did not advise that they 
were out-of-network or that a referral was needed. You say that a plan representative advised that no referral 
was needed. You also say that you should have been advised this would not be covered after the first 
appointment and not after more than $8,000 in services had accumulated. The Plan denied your request. The 
Plan says services received out-of-network are 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the Mohs surgery and related services (17311 x 2, 12053, 12042) 
provided on April 18, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs procedure (17313). 
 
You asked the Plan to pre-approve the Mohs procedure. You say that this procedure is recommended due to the 
size and location in the lower legs. The Plan denied your request. The Plan says there is no clear documentation 
to support why surgical cure and reconstruction would be compromised without the use of microscopic 
examination of surgical margins or why the lesion cannot be managed by standard excision. 
 
The Plan follows Medicare rules. Medicare rules say that Mohs Micrographic Surgery is indicated only when 
the likelihood of surgical cure and reconstruction would be compromised without use of immediate 
microscopic examination of the surgical margins. 
 
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 Mohs procedure. Our reviewer says 
that the requested Mohs procedure is not medically necessary. Our physician reviewer found the record indicates that the enrollee has squamous cell carcinoma of skin of left lower limb.  The record does not 
document that the likelihood of surgical cure and reconstruction would be compromised without use of 
immediate microscopic examination of the surgical margins. Therefore, the reviewer found that the requested 
Mohs 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 Mohs procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Mohs procedure (17313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
rendered on February 24, 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 Current Procedural Terminology (CPT) code - 99233-Q6 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that 50 minutes 
were spent.  
We looked at this coder'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 evaluation and management services (procedure code 99233) rendered on February 24, 2023.
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 inpatient rehabilitation is medically necessary. 
The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not 
meet the requirements for approval.  
 
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 at the current functional level, the enrollee needs routine physical therapy and 
occupational therapy, but does not need intensive therapies consisting of at least 3 hours of therapy per day at 
least 5 days per week with a multidisciplinary approach in an IRF. The complexity of the enrollees medical, 
rehabilitation, and nursing needs (combined complexity) does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our reviewer also found that the 
enrollees rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a 
skilled nursing facility (SNF).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 14, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim was billed correctly and diagnosis 
G45.8 is coverable. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that I65.21 has an Excludes1 note in relation to G45.8. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 14, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parenteral formula. 
 
You asked the Plan to pre-approve parenteral formula. 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 follows Medicare rules. Medicare rules say that parenteral nutrition is covered when certain criteria 
are met. 
 
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 parenteral formula. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not meet criteria 
to cover parenteral nutrition. Further, it seems the providers are requesting intraperitoneal nutrition, which does 
not appear to be 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 parenteral formula have not been met. Therefore, we decided that the Plan does 
not have to pre-approve parenteral formula.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D cytopathology and histopathology diagnostic 
testing (88361, 88312, 88305, 88112) provided January 10, 2023. 
 
You asked the Plan to pay for the WATS 3D testing. You say that the enrollee was diagnosed with a condition 
that prompted the doctor to order a WATS 3D analysis based on medical necessity The Plan denied your 
request. The Plan says this expense does not meet the requirements of the Plan benefits. 
 
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 pay for the WATS 3D testing. 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 gastroesophageal reflux disease and underwent an endoscopy with 
biopsy. A request was made for the WATS 3D cytopathology and histopathology diagnostic testing. However, 
the provided documentation does not describe the enrollee having Barrett's esophagus, dysplasia, or other signs 
of cancer or precancerous process of the esophagus or stomach to warrant this testing addition beyond standard 
biopsy and pathology. As this testing appears to not be for surveillance but rather for screening, it is not 
supported. Therefore, this request for WATS 3D will be considered 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 WATS 3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS 3D cytopathology and histopathology diagnostic testing (88361, 88312, 
88305, 88112) provided January 10, 2023.