Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 8, 2022 to 
February 6, 2022 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 8, 2022. The NOA was not received by the Plan until May 3, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided on 
January 8, 2022 to February 6, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe lenses (V2781, V2744), and does not have to waive 
the copayment for eyeglasses received on February 15, 2023. 
 
You asked the Plan to pay for deluxe lenses and waive the copayment for the eyeglasses. You say that you 
were told eyewear would be covered. The Plan denied your request. The Plan says the cost share for the 
eyeglasses was applied correctly. Deluxe lenses are not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 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 
$30 for eyeglasses after cataract surgery. 
 
We looked at the file and the Plan's rules. 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. Additionally, the deluxe lenses are not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for deluxe lenses (V2781, V2744), and does not have to waive the copayment for eyeglasses 
received on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content cap for bridge for 
teeth 22 and 27 and false tooth for bridge for teeth 23, 24, 25 and 26. 
 
You asked the Plan to pre-approve white glass with high gold content cap and a false tooth for a bridge. You 
say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says your dentist 
asked for a bridge to replace your missing teeth. To approve a bridge, you must be missing only one upper 
front tooth or only two lower front teeth. The two lower front teeth must be next to each other. You also cannot 
be missing any of your back teeth. Our dentist looked at the x-rays your dentist sent us and said you are 
missing other teeth. 
 
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. The Plan covers white glass 
with high gold content cap and a false tooth for a bridge when the services are medically necessary and reasonable.  
 
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 white glass with high gold content cap 
and a false tooth for a bridge. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found according to the guidelines, a fixed bridge may be considered to replace a single maxillary 
anterior tooth or two adjacent mandibular anterior teeth. In this case four mandibular anterior teeth are being 
replaced. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with high gold content cap and a false tooth for a bridge have not 
been met. Therefore, we decided that the Plan does not have to pre-approve white glass with high gold content 
cap for bridge for teeth 22 and 27 and false tooth for bridge for teeth 23, 24, 25 and 26.
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 necessary for the enrollee's 
medically complex needs. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of the intraosseous basivertebral 
nerve (BVN) for vertebrogenic lower back pain (64628).  
 
You asked the Plan to pre-approve the thermal destruction of the intraosseous basivertebral nerve (BVN) for 
vertebrogenic lower back pain. You say that the service is medically necessary. The Plan denied your request. 
The Plan says this service is considered experimental. 
 
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 thermal destruction of the 
intraosseous basivertebral nerve (BVN) for vertebrogenic lower back pain. Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found this 
service is considered experimental.  
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 thermal destruction of the intraosseous basivertebral nerve (BVN) for 
vertebrogenic lower back pain have not been met. Therefore, we decided that the Plan does not have to pre-
approve the thermal destruction of the intraosseous basivertebral nerve (BVN) for vertebrogenic lower back 
pain (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new dentures. 
 
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 January 24, 2023. 
Therefore, we decided that the Plan does not have to pre-approve new dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0672). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0672).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on March 15, 2023. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Lancets. 
 
You asked the Plan to pre-approve the Accu-Chek Lancets. You say that the services are necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME 
products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, 
the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use 
of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Accu-Chek Lancets. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek 
Lancets.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing provided on November 6, 2022. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that that the billed code is not listed on the 
Diagnostics Exchange Registry. 
 
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 billed with a single panel code as 
required. Additionally, per the Local Coverage Article for the Billing and Coding for Guardant360, A58192, 
CPT code 81479 is the appropriate code to bill for this testing. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have been met. Therefore, we decided that the Plan has 
to pay for the Guardant360 testing provided on November 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ceramic tooth #22, #27 
(D6740) and pontic tooth #23, #24, #25, #26 (D6245). 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says our dental expert found that there is no documented 
physical or neurological disorder present, and no narrative supporting any special needs for this member. 
Therefore, placing fixed prostheses (bridges) on teeth #18-21 and #28-31 does not meet the coverage criteria 
under the member's supplemental benefits. There are other treatments which may be medically appropriate or 
necessary. 
 
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. The Plan covers retainer 
crown and pontic when the services are medically necessary and reasonable.   
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 retainer crown and pontic. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the member is missing most of 
the lower teeth, only #18,21,22, 27, 28 and 31 remain. The requested bridge for the anterior teeth #22-27 is 
possible however the Plan limits fixed bridges to situations where the member has documented physical or 
neurological disability that would preclude the use of a removable appliance.  In this instance there has been no 
documentation that such a disability exists, only that the member has had issues with partial dentures in the 
past.  Given the Plan limitations there would be no medical necessity for the requested treatment of a fixed 
bridge from #22-27. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown - porcelain/ceramic tooth #22, #27 (D6740) and pontic tooth 
#23, #24, #25, #26 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19083 billed for date of service December 
23, 2022.  
 You asked the Plan to pay for procedure code 19083. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 19083 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 19083 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 19083 billed for date of service December 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Qutenza kit. 
 You asked the Plan to pre-approve the Qutenza kit. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
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 the Qutenza kit. Our reviewer says that 
you do not need this drug. Our physician reviewer found there is no evidence that you are allergic to or 
intolerant of the preferred forms of medication or that you have tried and not responded to these other forms of 
medication. There is no documentation as to why these other forms of medication would not be expected to be 
safe and effective.  
 
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 Qutenza kit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Qutenza kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364) provided on September 6, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that the computerized 
tomography (CT) scan of your mouth was deemed required and necessary for an emergency root canal to save 
top back tooth and stop the spread of severe infection and stop severe pain. The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 cone 
beam CT capture and interpretation with limited field of view  less than one whole jaw (D0364) provided on 
September 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve eight physical therapy visits. You say that you do not agree with the denial 
of services. The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
eight physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from February 24, 2023. 
 
You asked the Plan to pay for SNF care. You say that the enrollee needs rehabilitation. The Plan denied your 
request. The Plan says the enrollee no longer had skilled nursing facility 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 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 that 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 or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from February 24, 2023.