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

 
We decided that the Plan has to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the services requested are not 
medically 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 dental 
services 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 dental services. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the documentation indicates that there is 
significant coronal breakdown of teeth # 25 and 26. Core build up and crown restorations are medically 
reasonable and necessary. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve dental services.  
 
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 pay for procedure codes 75710 and 75625 billed for date of service 
October 7, 2022. 
 
You asked the Plan to pay for the billed services The Plan denied your request. The Plan says the services are 
inclusive to another code. 
 
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 find that the angioplasty services are included in the primary vascular procedure provided. Providers 
should not unbundle services. The medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 75710 and 75625 billed for date of service October 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization of 11 of the 13 requested physical therapy visits. 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 is 
functioning at a level of care which can improve with a home exercise program. The enrollee does not require 
continued input from a skilled therapist beyond the approved review of the home exercise program as ordered. 
 
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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 that the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services to improve the enrollees condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 nine home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Elite Comprehensive PGx panel 81401, 81406, 81479, 
81230 81240, 81241, 81291, 81355 and 81400 provided April 26, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were clearly medically necessary, as 
evidence by the enclosed requisition form from the enrollee' treat physician. The Plan denied your request. The 
Plan says this service does not meet the coverage requirements in the applicable Local Coverage Determination 
or National Coverage Determination. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found pharmacogenetic testing is available in conjunction with certain drug classes and may enable 
physicians to understand why patients respond differently to various drugs and to make better decisions about 
therapy. However, the goal of individualized therapy based upon pharmacogenetic testing has yet to be 
realized. There are no clinical notes provided that documents the rationale for testing on this enrollee. The 
service was not reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Elite Comprehensive PGx panel 81401, 81406, 81479, 81230 81240, 81241, 81291, 
81355 and 81400 provided April 26, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements. Services needed may be provided safely in 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee has strong criteria for an LTACH admission and is stable for discharge to 
that level of care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no 
required medical services identified that are available at the LTACH that are not available at the current health 
care setting being offered by the Plan.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Elite comprehensive PGx panel (81479, 81406, 81401, 
81400, 81381, 81355, 81291, 81241, 81240 and 81230) provided March 16, 2022. 
 
You asked the Plan to pay for  the genetic testing. You say that the services in question were clearly medically 
necessary as evidenced by the enclosed requisition form from the enrollee's treating physician. The Plan denied 
your request. The Plan says this service does not meet the Medicare coverage requirements. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the pharmacogenetics 
testing provided on date of service March 16, 2022, at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided records in this case consist of the test 
requisition form, a medication list and the test results, but records do not document the enrollee has a condition 
where clinical evaluation has determined the need for a medication that has a known gene-drug interaction(s) 
for which the test results would directly impact the drug management of the patients condition as required by 
the Local Coverage Determination (LCD) Pharmacogenomics Testing L39063. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for  the Elite comprehensive PGx panel (81479, 81406, 81401, 81400, 81381, 81355, 81291, 
81241, 81240 and 81230) provided March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, rear basket (K0108). 
 
You asked the Plan to pre-approve the rear basket. You say that the enrollee is looking to pursue other funding 
opportunities for these non-covered accessories but does need formal decision from the Plan in order to do so. 
The Plan denied your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, rear basket (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim implant abutment placement (D6051 x 2).  
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim implant abutment placement (D6051 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 provided on December 8, 2022. 
 
You asked the Plan to pay for procedure code 96374. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 find that CPT code 96374 is not supported in the medical record. Specifically, this service was a 
professional component / technical component indicator of 5. The service was billed with an outpatient hospital 
place of service (22). This code is an "incident to" code and is not separately payable in this setting. Based on 
this information, we decided that Medicare rules for coverage of procedure code 96374 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 96374 provided on December 8, 
2022.
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. The Plan denied your request. The Plan says the enrollee does not 
require around the clock access to a rehabilitation nurse or doctor. Services needed may be provided safely in 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service December 14, 
2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function.  
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 procedure code 99284. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented to the Emergency 
Department with pain and swelling in his right upper leg and calf for two days. Vital signs were normal. 
Examination of the right lower extremity was notable for mild tenderness and swelling at the medial knee joint, 
and diffuse lower leg tenderness and swelling. An ultrasound demonstrated a synovial cyst of the popliteal 
space. Elevation, Ace wrap, ice, and follow-up were advised. The documentation does not support medical 
decision making of moderate complexity. Therefore, code 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 for date of service December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on September 1, 2022.  
 
You asked the Plan to pay for the drug testing. You say that this should be paid as the testing was medically 
necessary. The Plan denied your request. The Plan says no order from the treating physician was submitted 
despite requests for this documentation.  
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating 
physician. An order is not required to be signed, but there must be medical documentation to support the intent 
for the testing. 
 
We looked at the file and Medicare rules. In this case, the file does not include a copy of an order for the 
rendered testing, nor does it include a progress note where the intent for the testing is documented. Based on 
this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you cannot afford the requested 
hospital bed. You also say that it will help you a lot since you cannot get up easily in a regular bed.  The Plan 
denied your request. The Plan says the requested hospital bed is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee has a condition that requires frequent positioning of the bed 
and mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory 
infections in a way that an ordinary bed is not able to. Therefore, the reviewer found that the requested semi-
electric hospital bed 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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0261).