Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel. 
 
You asked the Plan to pay for the PCR panel. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no medical records, outside of the lab order, were submitted for review. The 
service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the PCR panel have been met. There 
were no medical records submitted for this claim.. Therefore, we decided that the Plan does not have to pay for 
the respiratory polymerase chain reaction (PCR) panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says this is not an eligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe inserts (L3000). 
 
You asked the Plan to pre-approve the shoe inserts. You say that the enrollee has attempted conservative care. 
You also say that the custom orthotics would be beneficial to the enrollee. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom shoe inserts (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-urgent admission stay to a residential treatment 
facility. 
 
You asked the Plan to pay for a non-urgent admission stay to a residential treatment facility. You say that the 
services should be covered. The Plan denied your request. The Plan says this provider is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a non-urgent admission stay to a 
residential treatment facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the enrollee has ulcerations including of the heel that are more likely to be related to 
arterial insufficiency than the varicose veins. Additionally, the documentation does not support the medical 
necessity of ablation of the right greater saphenous vein in the presence of potentially limb threatening arterial 
occlusive disease. Doing so would deny the enrollee a potential conduit should surgical revascularization be 
required which, if used, could also fix the reflux. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says s the 
enrollee will not require a greater than 2 midnight stay. 
 
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 inpatient services. Our physician 
reviewer found that you were approved for left shoulder replacement surgery. The procedure is currently 
approved as an outpatient procedure. There is no documentation to support the expectation that you will require 
a greater than 2 midnight stay. Therefore, the request is 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 inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - resin base (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 15, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - resin base 
(D5212).
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 enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollees needs can be met at a lower level of care. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 14, 2020. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5214).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not 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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have new dentures because the 
ones you have now are causing issues in your mouth. 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 complete denture - maxillary (D5110) and complete denture - mandibular (D5120) but is limited to 
one procedure per 60 floating months. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5110 and D5120 on April 5, 2021. Therefore, these benefits were exhausted as 
of April 5, 2021. Therefore, we decided that the Plan does not have to pre-approve complete denture - 
maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not medically necessary. 
 
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. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Parkinson's disease and is described as having neuromuscular 
weakness. The enrollee was hospitalized in October 2022 with acute respiratory failure requiring intubation. 
The enrollee was in acute pulmonary edema due to Heart failure with preserved ejection fraction (HFpEF), 
with pleural effusions. Venous blood gases reportedly showed carbon dioxide retention. No arterial blood gas 
(ABG) test results are provided. The enrollee was described as requiring BiPAP at night after extubation, and 
was discharged to an assisted living facility on a home ventilator during sleep. There is no ABG done while 
stable to document chronic CO2 retention. There is no diagnosis of COPD or thoracic restrictive disease. The 
enrollee is unable to perform pulmonary function tests. There is no documentation that BiPAP has failed as an 
outpatient. If this enrollee does have chronic CO2 retention, may benefit from BiPAP during sleep. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP. Therefore, the 
enrollee does not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (DD7953) 
and an implant (D6010). 
 
You asked the Plan to pre-approve bone replacement graft and an implant. 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 pre-approve bone 
replacement graft for ridge preservation (DD7953) and an implant (D6010).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 71045. You say that this was coded correctly. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 32555. 
 
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 code 71045 
is a column II code to column I code 32555. This claim has 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 code 71045 billed for date of service November 28, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706-26) provided on December 15, 
2022. 
 
You asked the Plan to pay for the service. You say that the service performed was appropriate with the 
diagnosis code. The Plan denied your request. The Plan says the Medicare rules have not been met and the 
diagnosis codes do not show the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
Per review of the claim this was billed with diagnosis code Z13.6 (Encounter for screening for cardiovascular 
disorders), N28.1 (Cyst of kidney, acquired) which does not indicate the Centers for Medicare & Medicaid 
Services (CMS) criteria of a family history of abdominal aortic aneurysm, a man age 65 to 75 who has smoked 
at least 100 cigarettes in his lifetime, or other risk factors recommended by the United States Preventive 
Services Task Force. Also, documentation received does not indicate that the enrollee received the screening 
study for one of the CMS risk categories of a family history of abdominal aortic aneurysm, a man age 65 to 75 
who has smoked at least 100 cigarettes in his lifetime, or other risk factors recommended by the United States 
Preventive Services Task Force. Therefore, we decided that the Plan does not have to pay for the ultrasound, 
abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) 
(76706-26) provided on December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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. 
 
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 member does not need this item. Our physician reviewer found an arterial blood gas (ABG) while acutely ill was consistent with acute on chronic hypercarbic respiratory failure. There is no documentation of 
chroniccarbon dioxide (CO2) retention with an ABG done while stable. If that is present, the patient may 
benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Polio vaccine and administration (90713 and 90471) on 
October 7, 2022. 
 
You asked the Plan to pay for the Polio vaccine and administration. You say that the services should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Polio vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Polio vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for the Polio vaccine and 
administration (90713 and 90471) on October 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2022, 
to May 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 25, 2022, to 
May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment an inpatient hospital stay provided on November 30, 
2022, to December 7, 2022. 
 
You asked the Plan to waive the copayment an inpatient hospital stay. You say that you should not owe 
anything. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for inpatient hospital care.  
 
The Plan says you must pay a $2524 copayment for an inpatient hospital stay. Based on the Plan contract, 
however, you cannot be asked to pay more than $0 copayment for an inpatient hospital stay. Therefore, we 
decided that the Plan has to waive the copayment an inpatient hospital stay provided on November 30, 2022, to 
December 7, 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.