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

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #22, #23, #24, #25, #26, and 
#27. 
 
You asked the Plan to pre-approve the dental services. You say that you have not used your dental coverage 
and your dentist said you need the crowns.  The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the requested teeth can be restored without the need for 
crowns. 
 
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 the 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 the dental services. Our reviewer says 
that the crowns requested are not medically necessary. Our physician reviewer found that crowns are 
considered necessary when a significant amount of tooth structure is missing from decay or fracture and a full 
coverage restoration is the best method to add sufficient strength to allow the tooth to function. In this instance 
none of the teeth in question show any significant structural damage such as to require full coverage crowns. 
Given the lack of damage to any of the teeth there would be no medical necessity for the requested crowns. 
 
There is insufficient missing tooth structure as to make the need for crowns apparent. The Plan requires that 
multiple tooth surfaces and at least a single cusp must be significantly damaged to allow for a full crown 
restoration. As none of the teeth in question #22, #23, #24, #25, #26, and #27 have any notable structural loss, 
the criteria for a crown restoration would not be met. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750) for tooth #22, #23, #24, #25, #26, and #27.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 10, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sandostatin. 
 
You asked the Plan to pre-approve Sandostatin. You say that treatment with Sandostatin is warranted and 
appropriate due to the enrollee's medical condition and medical history. The Plan denied your request. The Plan 
says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Sandostatin.  
 
Benefits for Sandostatin 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the core buildup (D2950) for tooth #2 and 
#3 and the endodontic therapy (D3320) for tooth #5 provided on July 15, 2022, and August 17, 2022. 
 You asked the Plan to waive the coinsurance for the dental services. You say that you disagree with paying a 
coinsurance for the dental services. 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 50% 
coinsurance for in-network endodontic, periodontic, prosthodontic and oral surgery services after you annual 
dental allowance has been used.  
 
Prior to the date of service, the total amount used towards the $2,000 annual dental allowance was $1,873 
leaving a balance of $127 ($2,000 annual - $1,873 used). The total amount billed for the endodontic therapy 
(D3320) was $886 with a coinsurance of $443 ($886 billed x 50% coinsurance). The $127 balance left was 
applied leaving a responsibility of $316 ($443 coinsurance - $127 dental allowance). The total amount billed 
for each core buildup (D2950) was $116 with a coinsurance of $58 ($116 billed x 50% coinsurance). The total 
coinsurance for both core buildups (D2950) was $116 ($58 coinsurance x 2 core buildups). 
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the dental 
services 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 coinsurance for the core buildup (D2950) 
for tooth #2 and #3 and the endodontic therapy (D3320) for tooth #5 provided on July 15, 2022, and August 17, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation facility (IRF) 
stay provided on April 07, 2023, to April 11, 2023. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation facility (IRF) stay. You say that you 
are unable to afford the cost share applied. 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 $235 
copayment for inpatient hospital care.  
You have been asked to pay a $235 copayment for an inpatient rehabilitation facility (IRF) stay. This 
item/service falls within the inpatient hospital care 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. You have been asked to pay $1,175 for an IRF stay ($235 per day 
x 5 days = $1,175). Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
rehabilitation facility (IRF) stay provided on April 07, 2023, to April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GTC Liquid Trace Hematology Profile provided on June 
19, 2023. 
 
You asked the Plan to pay for the GTC Liquid Trace Hematology Profile. You say that this testing is medically 
necessary.  The Plan denied your request. The Plan says the requested test does not meet requirement for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. The DEX database shows that the GTC Liquid Trace Hematology 
Profile is not covered. Based on this information, we decided that Medicare rules for coverage of the GTC 
Liquid Trace Hematology Profile have not been met. Therefore, we decided that the Plan does not have to pay 
for the GTC Liquid Trace Hematology Profile provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not having low blood sugars that we are told of and is 
not taking insulin. Although a CGM might help the enrollee adjust diet and control blood sugars, the coverage 
criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 22, 2023. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF 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 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 and can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the service requested is not supported based on 
the records received.  
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested genetic testing is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage of BRCA1 and BRCA2 genetic 
testing have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing is 
considered medically necessary for an enrollee with a current diagnosis or a personal history of a cancer 
associated with the BRCA mutation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the provided medical records do not indicate a 
current diagnosis or a personal history of cancer.  
  Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement.  However, the documentation doesn't support the need for an IRF admission. The enrollee can 
receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99347 provided on April 12, 2023.  
 
You asked the Plan to pay for procedure code 99347. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 11721 
provided on April 12, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99347 provided on 
April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing. 
 
You asked the Plan to pay for COVID-19 testing. You say that there was a nurse table doing COVID-19 
testing, and you were not informed that you would be billed. The Plan denied your request. The Plan says this 
was not authorized and is not payable by the Plan. 
 
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 COVID-19 testing have been met. The 
Plan has requested medical records and they have not been submitted. Therefore, we decided that the Plan does 
not have to pay for COVID-19 testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard testing (0114U) provided on June 23, 2023. 
 You asked the Plan to pay for the EsoGuard testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the EsoGuard testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard testing (0114U) provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS pulmonary pressure sensor 
implantation (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS pulmonary pressure sensor implantation. You say that 
this is medically necessary. The Plan denied your request. The Plan says this 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 CardioMEMS pulmonary pressure 
sensor implantation. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this 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 CardioMEMS pulmonary pressure sensor implantation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS pulmonary pressure sensor 
implantation (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves 
as being medically necessary and/or reasonable at this time. Our physician reviewer found there is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81226 provided on May 19, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 81226. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure code 81226 provided on May 19, 2023, 
by an out-of-network (OON) provider.