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

 
We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2), gingival 
irrigation (D4921), two core buildups, including any pins when required (D2950 x2), and two retainer crowns 
(D6740 x2). 
 
You asked the Plan to pre-approve the guided tissue regenerations, gingival irrigation, core buildups, and 
retainer crowns. The Plan denied your request. The Plan says these services are not covered under the enrollee's 
benefit 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 pre-approve two 
guided tissue regenerations (D4266 x2), gingival irrigation (D4921), two core buildups, including any pins 
when required (D2950 x2), and two retainer crowns (D6740 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the medical notes do not show that the enrollee needs therapy 
for three hours or more per day, five days a week. The Plan says that the enrollee does not have complex care 
needs. The Plan says that the enrollee has been stable and that her therapy can be given at 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. The enrollee 
was admitted for rectal sheath hematoma. The enrollee's medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397). 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were 
medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the 
provider saw the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that for the requested orthosis, knee instability must be 
documented by examination of the beneficiary and objective description of joint laxity. 
 
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 knee orthosis and suspension sleeve. Our 
reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there 
is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective 
documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the 
base item is not covered. 
 
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 knee orthosis and suspension sleeve have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 22, 2019, 
through April 24, 2019, by the Hospital. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been observed for twenty-four (24) hours and 
treated as an outpatient. The Plan must follow Medicare rules. The rules say that inpatient hospital care is 
covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare 
and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross 
two midnights or more. 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 acute inpatient 
hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment 
are met in this case. Our physician reviewer found based on the documentation provided, this hospitalization 
does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not 
reasonable to expect that two midnights in the hospital would be required. The emergency department (ED) 
evaluation showed no acute life/limb threatening condition(s). The treating physician(s) had the remainder of 
April 22, 2019, and all of April 23, 2019, to further monitor the enrollee before deciding if two midnights of 
care (April 22, 2019, through April 24, 2019) would be required. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute 
inpatient hospital care provided on April 22, 2019, through April 24, 2019, by the 
Hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment 
supported porcelain fused to metal crown (D6060). 
 
You asked the Plan to pre-approve the prefabricated abutment and abutment supported crown. You say that you 
need these services provided. The Plan denied your request. The Plan says these services are not covered under 
your benefit package. 
 
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 pre-approve a 
prefabricated abutment (D6056) and an abutment supported porcelain fused to metal crown (D6060).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on November 5, 2020 to 
November 19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON psychotherapy services. You say that you feel that these services were 
not paid correctly. The Plan denied your request. The Plan says these services were provided out of network 
without authorization from the plan. 
 
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 psychotherapy services provided on November 
5, 2020 to November 19, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power-lift recliner provided on December 7, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the power-lift recliner. You say that this service is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the power-lift recliner provided on December 7, 
2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650). 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence that the 
provider ever examined the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when medically 
reasonable and necessary as specified in the 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 pay for the lumbar-sacral orthosis. Our reviewer 
says that the item was not medically reasonable and necessary. Our physician reviewer found an appropriate 
history and a physical examination of the back would reasonably be required to adequately assess whether the 
coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the 
lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is 
insufficient documentation of a credible evaluation and a credible physical examination of the back. 
 
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temazepam cap 7.5mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Temazepam cap 7.5mg.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder test provided to the enrollee on August 11, 
2020. 
 
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. 
The Plan says this is not a covered test. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee was evaluated for benign prostatic hyperplasia symptoms and microscopic hematuria. The provided 
genetic testing is a screening test for risk stratification. It is neither diagnostic nor treatment determining. As 
such, the provided genetic test was not medically necessary or reasonable to diagnose, treat or otherwise 
manage the enrollees condition. 
 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CXbladder test provided to the enrollee on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out of network dental visit. 
 
You asked the Plan to pre-approve the dental services. You say that there are no dentists that are close to you. 
You say that the closest dentist is over 45 minutes away from you. You say that you do not drive much 
anymore and when you do it is not that far. The Plan denied your request. The Plan says the requested provider 
is out of network. The Plan says that services are only covered when received by a participating provider. The 
Plan also says there are in network providers available in your area. 
 
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, dental services must be received by a 
participating provider in order to be covered. Therefore, we decided that the Plan does not have to pre-approve 
an out of network dental visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically 
necessary. The Plan denied your request. The Plan says there is no expectation enrollee will require greater 
than a 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee is undergoing a planned total shoulder arthroplasty. The 
enrollee is medically stable. The planned procedure is listed under CPT code 23472 is not listed on the CMS 
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If 
the member experiences any peri- or post-operative complications, reconsideration for inpatient level of care 
can be then be performed. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike rental. 
 
You asked the Plan to pre-approve an exercise bike rental. You say that your surgeon prescribed the bike for 
recover from knee surgery. The Plan denied your request. The Plan says exercise bikes do not diagnose or treat 
a medical condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Home exercise/ 
physical therapy equipment that can be obtained without a prescription is considered to be an over-the-counter 
supply, is not considered DME, and is therefore ineligible for coverage. Therefore, we decided that the Plan 
does not have to pre-approve an exercise bike rental.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant-supported dentures (overdentures). 
 
You asked the Plan to pre-approve the overdentures. You say that you need this service. The Plan denied your 
request. The Plan says this service is excluded from coverage. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant-supported dentures (overdentures).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the ambulance transport provided on August 20, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were taken by 
ambulance instead of having your wife drive you. You say that you do not have the money to pay this bill. The 
Plan denied your request. The Plan says that the copayment applied 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 does not say in clear and accurate terms 
when you should expect to pay a $0 copayment or a $200 copayment. 
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $200 
copayment. The Plan contract does not clearly say when enrollees should expect to pay a $0 copayment or a 
$200 copayment. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayment for the ambulance transport 
provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) for tooth #9. 
 
You asked the Plan to pre-approve the dental service. You say that the service should be covered. The Plan 
denied your request. The Plan says custom abutment 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 Plans 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 pre-approve a 
custom abutment (D6057) for tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
for tooth #18. 
 
You asked the Plan to pre-approve the bone replacement graft. The Plan denied your request. The Plan says 
this service is not covered under the enrollee's benefit plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation (D7953) for tooth #18.