Persius/hicric huggingface dataset:
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 that the enrollee is medically stable and 
will benefit to transfer to an LTACH, see the medical records provided support the need for care. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 enrollee was admitted with foot cellulitis/osteomyelitis and ischemic ulceration of 
left foot in the setting of critical limb ischemia of the lower extremity secondary to peripheral artery disease following recent revascularization. The record indicates that the enrollee has ongoing acute medical 
issues and still requires acute care services. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
August 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure needed to be redone because 
your previous provider retired and there was no way to obtain your x-rays. 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 Plan's 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 August 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the complete series of x-ray images (D0210) 
provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0210) and core buildup (D2950) 
provided on July 31, 2023 to August 24, 2023. You asked the Plan to pay for the intraoral x-rays (D0210) and core buildup (D2950). 

You say that you believe you are not being charged correctly by an out-of-network provider. The Plan denied your request. The Plan says your benefit for the intraoral x-rays has already been exhausted. The Plan also says core buildup is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 intraoral x-rays was exhausted on date of service April 5, 2023. The record also 
shows core buildup is not a service covered by your dental benefit. Therefore, we decided that the Plan does 
not have to pay for the intraoral x-rays (D0210) and core buildup (D2950) provided on July 31, 2023 to August 
24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (41899) and the alveoplasty (41874) provided 
by an out-of-network provider on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to have the dental 
extractions. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the dental services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 
extractions (41899) and the alveoplasty (41874) provided by an out-of-network provider on June 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial reconstruction services related to gender 
dysphoria. 
 You asked the Plan to pre-approve facial reconstruction services related to gender dysphoria. You say that you 
are appealing the denial of this care as cosmetic and non-covered. Per regulations and standards of care, this 
should be a covered treatment. The Plan denied your request. The Plan says this type of surgery is considered 
cosmetic and not medically necessary when performed as part of gender reassignment. 
 
The Plan follows Medicare rules. Medicare rules say that cosmetic surgery and related services, except as 
required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, 
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 facial reconstruction services related to 
gender dysphoria. Our reviewer says that service is not medically necessary. Our physician reviewer found that 
the record indicates that the enrollee has gender dysphoria. The record provided does not document the 
presence of functional impairment, the presence of congenital, acquired, traumatic or developmental anomalies, 
or required for the prompt repair of accidental injury or to improve the functioning of a malformed body 
member. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facial reconstruction services related to gender dysphoria have not been met. 
Therefore, we decided that the Plan does not have to pre-approve facial reconstruction services related to 
gender dysphoria.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services. The Plan denied 
your request. The Plan says SNF care is not medically necessary. 
 
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 that 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 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has compensated respiratory 
failure and no documented failure of bilevel positive airway pressure (BiPAP) or escalation of therapy 
required. Hence, no indication for home ventilator per documentation or data provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you are experiencing pain in the knee. The Plan 
denied your request. The Plan says the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will 
approve Euflexxa. 
 
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 Euflexxa. Our reviewer says that you 
do not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found you have not tried 
and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record does not show that 
these drugs would likely be less effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate services. You say that this procedure is necessary 
due to the failure of conservative treatments. The Plan denied your request. The Plan says this procedure is not 
supported by research and is not covered. 
 
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 bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that bone marrow aspirate is considered experimental/investigational for 
use as bone graft material and 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 bone marrow aspirate services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bone marrow aspirate services (20939).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for 95938, 95939, and G0453. We decided that the Plan does not have to pay for 95999.

You asked the Plan to pay for neuromonitoring services (procedure codes 95938, 95939, 95999, G0453) rendered on August 22, 2022. You say that this was medically necessary. The Plan says that this was not medically necessary.

We decided that the Plan has to pay for 95938, 95939, and G0453.

The Plan must follow Medicare rules. Medicare rules say that somatosensory-evoked potentials and intraoperative neuromonitoring are covered for resection of epileptogenic brain tissue or tumor.

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 for G0453, 95938, and 95939. Our reviewer says that the enrollee was noted to have undergone a right frontal craniotomy for removal of mass/tumor. This is a covered indication, per the LCD. Likewise, SSEPs are covered for intraoperative monitoring. In as much it can be said that CPT codes G0453, 95938 and 95939 were all supported in the records provided for review.

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 item/service at issue have been met. Therefore, we decided that the Plan has to pay for 95938, 95939, and G0453.

We also decided that the Plan does not have to pay for 95999.

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 for CPT 95999. Our physician reviewer found there was no documentation to support the provision of CPT 95999. This may have referred to train of four testing which would otherwise be inherent to the monitoring of motor evoked potentials. As such, this code is not supported.

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 item/service at issue have not been met. Therefore, we decided that the Plan does not have to pay for 95999.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87640-59) provided August 16, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 the laboratory service. Our reviewer found the medical 
records do not support the use of lab code 87640 being billed in addition to lab code 87641, as lab code 87641 
includes the lab code 87640 and documentation does not support 87640 being done. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (87640-59) provided August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
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 a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
 
 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 billed service. Our reviewer found that 
the enrollee presented to the emergency room after stepping on something with the right foot. The foot was 
without visible abnormality. The x-ray showed no bony abnormalities. The history and physical are problem-
focused and appropriate.  The medical decision making is not of moderate complexity.  As such, the billing of 
CPT 99284 is not supported.   
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99284 billed for date of service July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this amount. 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. The Plan previously paid $102 
toward the dental benefit for date of service May 31, 2023. The allowed amount of this claim is $1,833, 
resulting in a payment amount of $1,398 because this exhausts your $1,500 combined dental benefit. 
 
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 August 9, 2023. 
Therefore, we decided that the Plan does not have to pay for dental services provided on August 9, 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 please see additional clinicals to support admission 
to IRF. The Plan denied your request. The Plan says admission to an IRF is not reasonable or 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 the complexity of the enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
on supplemental oxygen at baseline and is receiving hemodialysis. She is currently at home and does not 
require the oversight of a rehabilitation physician. The enrollee does not require rehabilitation nursing for 
complex wound care, parenteral nutrition or tube feedings, tracheostomy management or neurogenic bowel and 
bladder management. Her medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation. The enrollee required minimal assistance to contact guard 
assistance for bed mobility, transfers and ambulating with a walker. The enrollee has had a decline from her 
baseline level of function and may benefit from occupational and physical therapies as well as supervision and 
assistance, but she does not require the intensity of therapies provided on acute inpatient 
rehabilitation.  Therefore, the enrollee's rehabilitation admission 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 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.