Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on May 13, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you are entitled to the deeper 
periodontal cleaning which is also included in the overall maintenance cleaning twice per year. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance provided on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not use insulin. 
 
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 monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to be a non-compliant diabetic, who is prescribed only oral medications to treat her 
diabetes. There is no documentation of how often the enrollee checks her blood glucose. There is no evidence 
that the enrollee uses the results of blood glucose testing to self-adjust self-administered insulin multiple times 
per day.  As such, the documentation does not support that the requested CGM is currently medically necessary 
or reasonable. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical/thoracic interlaminar epidural injection for the 
enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation submitted provides no additional information that justifies the 
request. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the literature states that epidural injections may be repeated only as medically necessary. In this case the 
documentation states that the cervical epidural injection performed on 3/11/2020 only decreased her pain for 1 
day. The review has determined that the requested cervical/thoracic interlaminar epidural injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical/thoracic interlaminar epidural injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET imaging (78815) provided on May 20, 2020. 
 
You asked the Plan to pay for the PET imaging. You say that you would like reconsideration because the 
service rendered was medically necessary. The Plan denied your request. The Plan says the diagnosis code 
billed is not listed as an acceptable diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET imaging have not been met. Specifically, per CMS Change Request 8739 (Transmittal 
3162), there are certain diagnosis codes that should be billed for PET procedures to inform the subsequent 
treatment strategy of cancerous tumors. Diagnosis code C32.9 is not listed as an acceptable code. Therefore, we 
decided that the Plan does not have to pay for PET imaging (78815) provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care received on a cruise on January 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a lack of information. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
Despite multiple attempts, the plan did not receive an itemized bill/proof of payment for the services at issue in 
this case. Therefore, we decided that the Plan does not have to pay for emergency care received on a cruise on 
January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have tried TMS with poor success in the past. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve psychiatric transcranial magnetic stimulation (TMS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) provided on May 28, 2020. 
 
You asked the Plan to pay for the extraction. You say that you needed to see the first surgeon that was available 
due to your situation. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7210) provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuropsychological testing services (96116, 96132, 
96133, 96136, 96138, 96139)provided on November 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for neuropsychological testing services. You say that these services should be 
covered. The Plan denied your request. The Plan says these services were not authorized. 
 
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 has network providers 
available who can provide 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 neuropsychological testing services (96116, 
96132, 96133, 96136, 96138, 96139)provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of 
intraoral x-rays (D0210), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on 
June 23, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and 
topical application of fluoride varnish. You say that you understood that preventive services were covered 
without copayments, and all of these services were preventive. The Plan denied your request. The Plan says 
your $1,000 benefit maximum was met before the date of service in question. 
 
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, the Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on January 29, 2020 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral 
x-rays (D0210), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on June 23, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110 x 
5) provided on January 30, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were given an oral rinse for your pain. You 
say that the provider in this case ground down your sharp teeth without any discussion, resulting in your 
temporary prosthetic device no longer fitting properly. You say that the ill-fitting prosthetic has caused further 
pain. You also say that the grinding of your teeth has complicated the creation of your final prosthetic implant. 
The Plan denied your request. The Plan says palliative treatment of dental pain is not listed as 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
palliative (emergency) treatment of dental pain (D9110 x 5) provided on January 30, 2020.  
 
Your complaint about the dentist providing services without discussing them is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) on September 13, 2019, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that you do not have money to pay for services 
and that they were referred by your doctor. The Plan denied your request. The Plan says you received non-
emergent services by an unauthorized out-of-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 has network providers 
available who can provide 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 outpatient visit (99214) on September 
13, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on March 31, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were not advised there was more than 1 
dental option when you signed up for your plan. You say that the emergency root canal was not planned. You 
say that you would hope at least 50% payment would be fair. The Plan denied your request. The Plan says root 
canals are not a covered service under your dental plan. 
 
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, the root canal is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) 
provided on March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) provided 
February 24, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived due to the poor quality of the service you received. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the 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 an 
emergency room visit (99284) provided February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy treatments for varicose veins. 
 
You asked the Plan to pre-approve the sclerotherapy. You say that you feel this treatment is needed. The Plan 
denied your request. The Plan says there is insufficient evidence showing that a 3-month trial of conservative 
therapy was done as the recommendation for compression stockings was not made until August. 
 
The Plan follows Medicare rules. Medicare rules say that varicose vein treatments are covered for enrollees 
with certain symptoms who have failed a 3-month trial of non-surgical treatments.  
 
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 sclerotherapy. Our reviewer says 
that the requested treatment is not shown to be medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not meet coverage criteria and does not support the medical necessity 
of the procedures in question.  There is inadequate documentation that the patient is having significant 
symptoms from the varicose veins and there is inadequate documentation that efforts were made for 
conservative treatment prior to the decision to plan three sessions of sclerotherapy. 
 
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 sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sclerotherapy treatments for varicose veins.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet destruction for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the last procedure improved 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the request does not meet the requirement of at least 50% pain relief for 6 months. Therefore, the request 
is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve paravertebral facet destruction for the enrollee.
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 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 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 already available at 
the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. 
It appears appropriate to continue care at the current facility until more stable and ready for a transfer to a lower 
level of care soon. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility visit (99305) provided on 
November 5, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the initial nursing facility visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 initial nursing facility visit (99305) provided 
on November 5, 2019, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroconvulsive Therapy services provided on June 24, 
2020. 
 
You asked the Plan to pay for the Electroconvulsive Therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says your out of network provider 
did not submit medical records to show this treatment was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. You did not have prior authorization for out of network care. Your provider was 
asked to submit medical records to demonstrate medical necessity for this treatment but did not respond. 
Therefore, we decided that the Plan does not have to pay for the Electroconvulsive Therapy services provided 
on June 24, 2020.