Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (codes 96133, 96136, 96137, 
93168, and 96139). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the enrollee is in need of 
neuropsychological testing as part of their epilepsy surgery work up, to determine the best possible surgical 
options and cognitive outcomes related to dominant temporal lobe surgery. The Plan denied your request. The 
Plan says the number of units requested for this service is high based on documentation of the enrollee's current 
treatment needs. The Plan also says that the initial ten units approved should meet the enrollee's needs.  
The Plan follows Medicare rules. Medicare rules say that examples of problems that might lead to 
neuropsychological testing are listed in the Medicare rules section of this letter. 
 
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 neuropsychological testing. Our 
reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found this 
enrollee does not meet the criteria as they are not showing severity of symptoms that would warrant this type of 
diagnostic treatment and is therefore not appear medically necessary or reasonable. The neuropsychological 
testing as outlined in the documentation is unclear for the reasoning of the total of 26 units of testing to be 
obtained. Our reviewer also found that it is therefore found not to be reasonable or medically necessary for 
presurgical clearance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (codes 96133, 96136, 96137, 93168, and 96139).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869), 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is multi-level disease to T12-L5 involving facet joints, lateral recesses, 
and discs. Given the diffuse disease, the medical necessity of treatment of only L2-3 is not established 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869),
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on April 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that skilled nursing services are needed to help the 
enrollee reach maximum functioning. The Plan denied your request. The Plan says the enrollee no longer 
requires skilled services on a daily inpatient basis. 
 
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 pre-approve 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse.  The enrollee does not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test results are proof of the services rendered. 
The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on November 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa. 
  
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99183 for date of service February 21, 2023. 
 
You asked the Plan to pay for procedure code 99183. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99183 is physician or other qualified health care 
professional attendance and supervision of hyperbaric oxygen therapy, per session. 
 
We find that CPT code 99183 is not payable as billed. Specifically, this service was billed with place of service 
22 (outpatient). The documentation shows that the enrollee was inpatient for this date of service. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99183 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99183 for date of service February 
21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrolled is a fall risk, has no support at the 
home, and needs to be in a skilled nursing facility because to withdraw from painkiller. The Plan denied your 
request. The Plan says the enrollee's records do not show that you need skilled therapy in an inpatient setting on 
a daily basis. Services needed may be provided safely in a lower level of care. 
 
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 pre-approve 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $3,000 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on April 19, 
2023. 
 
You asked the Plan to pay for 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 October 28, 2020. 
Therefore, we decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on 
April 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 174 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional 174 routine transportation trips. You say that you need the 
additional 174 trips to get back and forth from your dialysis appointments. The Plan denied your request. The 
Plan says you have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve an 
additional 174 trips for your dialysis appointments.  Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve an additional 174 routine transportation trips (A0120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
November 15, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you did not ask for a 
diagnostic mammogram. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $45 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $45 copayment for the diagnostic mammogram. This item/service falls within 
the outpatient diagnostic tests, including ultrasounds 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 waive the 
copayment for the diagnostic mammogram provided on November 15, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. You say that prescribing the enrollee the Plan's preferred drugs 
would prolong the enrollee's suffering. You say that the enrollee has also tried and failed several systemic and 
topical treatments including Skyrizi, Cosentyx, Taltz and topical clobetasol. The Plan denied your request. The 
Plan says that the 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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found that the enrollee has plaque psoriasis, and the 
medication is a new start. However, there is no indication that the enrollee has tried and failed the Plan's 
preferred step one alternatives. Also, there is no indication that the enrollee has a contraindication to or would 
have an adverse effect from the Plan's preferred step one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on December 07, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration of the denied claim. 
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 an x-ray provided on 
December 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 80053, 83615, 96413, 85025 rendered 
on June 16, 2020. 
 
You asked the Plan to pay for the procedure codes 80053, 83615, 96413, 85025. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that your claim was not received timely. 
 
The Centers for Medicare and Medicaid Services state that any request for appeal must be filed within 60 days 
of the Plans initial determination. The record shows that the Plan issued their determination on July 20, 2020. 
The record also shows that your appeal was received on March 7, 2023. Your request was received more than 
60 days after the Plans initial denial. There is no evidence that you had good cause to file your appeal beyond 
the 60-day time limit. 
  
 
 
 Therefore, we decided that the Plan does not have to pay for  the procedure codes 80053, 83615, 96413, 85025 
rendered on June 16, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing because the enrollee was 
hospitalized with a broken tibia. You say the enrollee is undergoing physical therapy for strength and return to 
normal mobility and is non-weight bearing for up to six weeks. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare guidelines for services in a SNF.  
 
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 pre-approve 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee appears unable to participate in skilled therapy. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy, electrical stimulation, vasopneumatic 
devices, and subcutaneous injection services performed on February 4th, 2023.  
 
You asked the Plan to pay for the physical therapy, electrical stimulation, vasopneumatic devices, and 
subcutaneous injection services. You say that the services were medically necessary. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 physical therapy, electrical stimulation, 
vasopneumatic devices, and subcutaneous injection services. Our reviewer says that the serviced were not 
medically necessary. Our physician reviewer found electrical stimulation for polyneuropathy is not medically 
necessary. The injections have no evidence-based support and are not medically necessary SSA 1862 (a)1(A). 
The enrollee is functionally able to do a home exercise program for chronic polyneuropathy. unique input from 
a skilled therapist 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 physical therapy, electrical stimulation, vasopneumatic devices, and 
subcutaneous injection services have not been met. Therefore, we decided that the Plan does not have to pay 
for the physical therapy, electrical stimulation, vasopneumatic devices, and subcutaneous injection services 
performed on February 4th, 2023.
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 requires physical therapy to address their 
balance and strength. The Plan denied your request. The Plan says an IRF admission 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 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.