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

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor (33285, 
C1764). 
 
You asked the Plan to pre-approve insertion, subcutaneous cardiac rhythm monitor. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requested service 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 insertion, subcutaneous cardiac rhythm 
monitor. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  Our physician reviewer found this enrollee has no history of cryptogenic stroke, or 
previous syncope. The enrollee will not benefit from this device and does not meet the requirement of this 
implantable device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion, subcutaneous cardiac rhythm monitor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor (33285, 
C1764).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), retainer 
crown, porcelain/ceramic (D6740) and prosthodontics fixed, pontic - porcelain/ceramic (D6245). 
 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for periodontal scaling and root planing has already been exhausted 
and retainer crowns and pontics are not covered services. 
 
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 periodontal scaling and root planing was exhausted. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scaling and root planing (D4341), retainer crown, 
porcelain/ceramic (D6740) and prosthodontics fixed, pontic - porcelain/ceramic (D6245).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
testing as a screening is not a covered benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that psychological testing is only covered under 
certain medical indications.  
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing was requested prior to bariatric 
surgery. There are no medical records to show the services are indicated for a specific medical problem. Based 
on this information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve psychological testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee's acute needs have been met and stabilized in the acute care setting. You 
say the enrollee is stable to transfer to the LTACH for the continuation of care. The Plan denied your request. 
The Plan says criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories (K0835, 
K0400, E0953, E0955, E0973, E0978, E1002, E1012, E1028, E231, E2342, E2365, E2609, E2617). 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories . You say that you are at risk of 
falling. The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a group 2 power wheelchair and accessories is being requested for use in a SNF or hospital.  
Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories 
(K0835, K0400, E0953, E0955, E0973, E0978, E1002, E1012, E1028, E231, E2342, E2365, E2609, E2617).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block.  
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block is investigational 
and not medically necessary for chronic knee pain.  
 
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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case.  
Our physician reviewer found that this is considered an experimental therapy and there are ongoing clinical 
trials to determine the role of genicular nerve block and radiofrequency ablation (RFA) in the management of 
knee pain. Therefore, the request is deemed not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging, an eye injection, and a 
bevacizumab injection provided on October 07, 2022. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging, an eye injection, and a bevacizumab injection. 
You say that these services were medically necessary. 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 ophthalmic diagnostic 
imaging, an eye injection, and a bevacizumab injection provided on October 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
image (D0210), and periodontal maintenance (D4910) provided by an out-of-network provider on February 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was an out-of-
network provider and would like the Plan to cover the charges. 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 a periodic oral evaluation (D0120), the intraoral radiographic image (D0210), and periodontal 
maintenance (D4910) provided by an out-of-network provider on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided between January 3, 2023, and 
January 17, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are appealing the denial of payment. The 
Plan denied your request. The Plan says these services are not covered under your contract under any normal 
circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine.  Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided between January 3, 2023, and January 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided on November 14, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an E0601 device is covered for the treatment of 
obstructive sleep apnea (OSA) if criteria listed in Medicare Rules section is met. 
 
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 CPAP device. Our reviewer says that 
you do not need this medical item. Our physician reviewer found the provided records in this case do not 
document an apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 
15 events per hour with a minimum of 30 events; or, an AHI or RDI is greater than or equal to 5 and less than 
or equal to 14 events per hour with a minimum of 10 events and documentation of: excessive daytime 
sleepiness, impaired cognition, mood disorders, or insomnia; or, hypertension, ischemic heart disease, or 
history of stroke and the patient and/or their caregiver has received instruction from the supplier of the device 
in the proper use and care of the equipment. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pay for the continuous positive airway pressure (CPAP) device (E0601) provided on November 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is necessary because the enrollee 
has a serious, life-threatening constellation of acute medical problems.  The Plan denied your request. The Plan 
says the enrollee does not meet all the requirements for admission to an IRF.  
 
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 documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical, needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
have a need for physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be 
provided in a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the cranial cavity. 
 
You asked the Plan to pre-approve the CT scan. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 to pre-approve a CT scan. Our reviewer says that a CT 
scan is medically necessary. Our physician reviewer found that you have a three-month history of bilateral 
otalgia and have had an endoscopic evaluation. You have also tried over the counter medications. The probable 
diagnosis is Eustachian tube dysfunction, however the provider desires to look at the mastoid bones for other 
potential causes such as mastoiditis, cholesteatoma, etc. The requested CT of the mastoids is a reasonable 
request and should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the cranial cavity.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 11, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not believe the 
services you received should count as an emergency room visit. 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 $110 
copayment for in-network emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room visit. This item/service falls within the 
in-network emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency room visit provided on February 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for massage therapy. 
 
You asked the Plan to provide coverage for massage therapy. You say that your doctor prescribed massage 
therapy to help treat your long-term chronic back pain that over-the-counter medications do little to relieve. 
You say that the pain has extended to your legs, causing discomfort when you walk. The Plan denied your 
request. The Plan says massage therapy is excluded per Medicare Guidelines. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to provide coverage for massage therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on November 
21, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you would like the medical records reviewed and 
the claim to be reprocessed and paid. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) 
provided on November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request for 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 the office visit and the drug testing provided on August 11, 
2022, and the office visit provided on January 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visits and the drug testing. You say that you thought that this provider 
was in-network. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
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 the office visit and the drug testing provided on 
August 11, 2022, and the office visit provided on January 12, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on September 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
documented and billed as Incident to Physicians Services with direct physician supervision. 
 
The Plan must follow Medicare rules. Medicare rules say that the services must be an integral, although 
incidental, part of the physician's personal professional services, and they must be performed under the 
physician's direct supervision.  
 
We looked at the file and Medicare rules. The submitted documentation does not show that the requested 
therapy services, provided by a social worker, were incident to physician's services, or that they were provided 
under direct supervision of a physician. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the therapy 
services provided on September 19, 2022.