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

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #19. 
 
You asked the Plan to pre-approve the dental service. You say that you need the dental services approved.  The 
Plan denied your request. The Plan says the provided clinical information does not show that there is no 
evidence that support a crown for tooth #19. 
 
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 
service 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 service. Our reviewer says 
that the crown for tooth #19 is not medically necessary. Our physician reviewer found that the x-ray that was 
submitted is of the molar area in the upper jaw. Tooth #19 is a molar on the lower left side of the jaw. Without 
an x-ray of tooth #19, a medical necessity determination cannot be made. Based on the lack of information for 
tooth #19 included, a crown (D2752) 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 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2752) for tooth #19.
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 the most appropriate 
discharge disposition for the enrollee, given prior active lifestyle living at home and driving, requiring 
continued care for acute Spinal Cord injury. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare 
guidelines, services may continue to be provided in the current inpatient hospital. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: 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 is expected to be able to tolerate 3 hours 
of therapy per day and improve in a short amount of time to be able to return home safely with family. The 
Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines.  The 
Plan says that the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80076 billed for date of service March 10, 
2023.   

You asked the Plan to pay for procedure code 80076. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 80076 is bundled into 
payment for code 80053. 
 
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 80076 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 80076 billed for date of service March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room services provided on 
March 31, 2023, and April 13, 2023, the inpatient hospital stay provided from April 13, 2023, to April 17, 
2023, and the radiology services provided on May 8, 2023. 
 
You asked the Plan to waive the copayments for the emergency room visit, the inpatient hospital stay, and the 
radiology services. You say that you disagree with the copayments. 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 $95 
copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $250 
copayment per day, for days 1 to 7 per admission, for an inpatient hospital stay. Your contract with the Plan 
also clearly says that you must pay a $40 copayment per provider, per date of service, for radiology services. 
 
You have been asked to pay a $95 copayment for each emergency room visit provided on March 31, 2023, and 
April 13, 2023. These items/services fall within the emergency care benefit category.  You have been asked to 
pay a $250 copayment for the inpatient hospital stay provided from April 13, 2023, to April 17, 2023. You 
have been asked to pay a total of $1,000 for the hospital stay ($250 copayment x 4 days = $1,000). This 
item/service falls within the inpatient hospital care benefit category. You have also been asked to pay a $40 
copayment for the radiology services provided on May 8, 2023. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 
copayments for the emergency room services provided on March 31, 2023, and April 13, 2023, the inpatient 
hospital stay provided from April 13, 2023, to April 17, 2023, and the radiology services provided on May 8, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio device. 
 
You asked the Plan to pre-approve the Cala Trio device. You say that this item is medically necessary and 
effective for essential tremor. The Plan denied your request. The Plan says the Cala Trio therapy system is not 
considered medically necessary. Current medical literature does not consider this item to be standard medical 
treatment for tremor. 
 
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 Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that this device is effective for the 
patient's tremor. The requested K1018 is not the standard of care for this patient's tremor according to current guidelines.  
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Cala Trio device.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantation of BaroStim Neo device.

You asked the Plan to pre-approve the BaroStim Neo device. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is considered experimental and therefore 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 BaroStim Neo device. Our reviewer says that the requested the BaroStim Neo device is not considered medically reasonable and necessary in this case. Our physician reviewer found that there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of BaroStim Neo in patient management. Therefore, the reviewer found that the requested BaroStim Neo device 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 the BaroStim Neo device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of BaroStim Neo device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#7. 
  
You asked the Plan to pre-approve the dental services. You say that the dental services meet the coverage 
criteria, and the x-rays show the dental services are medically necessary. The Plan denied your request. The 
Plan says the denial of authorization for the crown and core buildup is correct, because the severe root decay 
near the bone level and into the pulp/nerve canal do not offer a favorable prognosis for this tooth. 
 
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. 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 crown and core buildup for tooth #7 is not medically necessary. Our physician reviewer found that the 
x-rays were reviewed. Tooth #7 shows extensive decay to the level of the bone and onto the root structure of 
the tooth with minimal remaining health tooth structure. The prognosis of this tooth is poor to hopeless, and 
alternate treatment from a buildup and crown is needed. A buildup and core should not be placed on a tooth 
with a hopeless prognosis. 
 
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 (D2740) and core buildup (D2950) for tooth #7.
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 prefer to be admitted to an acute rehabilitation 
program because you were independent before you were hospitalized and want to return to being independent. 
You say that you are eager to participate in three hours of aggressive rehabilitation that an acute rehab can offer 
you . 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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility  
 
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 pay for inpatient hospital services provided on December 13, 2021, 
to December 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.51, 
R65.20 and N17.0 are supported in the record, therefore the claim should be paid at the DRG originally billed. 
The Plan denied your request. The Plan says principal diagnosis code A41.51 and secondary diagnosis codes 
R65.20 and N17.0 are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.51, defined as sepsis due to 
Escherichia coli, secondary diagnosis R65.20, defined as severe sepsis without septic shock, and secondary 
diagnosis N17.0, defined as acute kidney failure with tubular necrosis. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that principal diagnosis A41.51 and secondary diagnoses R65.50 and N17.0 are not supported in the 
documentation. Our physician reviewer found the documentation does not sufficiently support principal 
diagnosis A41.51 as the Sepsis 3 criteria were not met, showing insufficient evidence of a dysregulated 
response leading to organ failure as required. Therefore, the documentation also does not sufficiently support 
secondary diagnosis R65.20. The documentation does not sufficiently support secondary diagnosis N17.0 
because although kidney function worsened slightly after fluids suggesting possible acute tubular necrosis, the 
documentation did not show urine non-hyaline casts, high urinary sodium, or other evidence of this condition 
to verify. Prerenal azotemia was evidenced.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 13, 2021, to December 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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 need acute care. The Plan denied your request. 
The Plan says the criteria for admission to the acute inpatient rehabilitation setting have not been met.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that while the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for procedure code U0005. We decided that the Plan does not have to pay 
for procedure codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, and 87798.  
 
You asked the Plan to pay for the lab testing billed for date of service April 14, 2023. You say that the treating 
physician determined the testing was medically necessary. The Plan says that one code must be submitted for 
the panel. 
 
We decided that the Plan has to pay for procedure code U0005.  
 
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 for code U0005 is infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-
19]), amplified probe technique, making use of high throughput technologies, completed within 2 calendar days 
from date of specimen collection (list separately in addition to either code U0003 or U0004).   we have confirmed that code U0005 is an add-on code that has been billed with appropriate primary procedure 
code, U0004. Based on the claim submitted, Medicare billing criteria have been met. Therefore, we decided 
that the Plan has to pay for procedure code U0005 billed for date of service April 14, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87500, 
87502, 87532, 87541, 87581, 87641, 87651, and 87798. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This panel testing was not billed with a single code as required. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87500, 87502, 87532, 
87541, 87581, 87641, 87651, and 87798 billed for date of service April 14, 2023. 
 
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.