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

 
We decided that the Plan does not have to pre-approve an occlusal guard. 
 
You asked the Plan to pre-approve these services. You say that you suffer from headaches and jaw pain. The 
Plan denied your request. The Plan says the services are not covered. 
 
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 an 
occlusal guard.
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 LTACH care is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for LTACH admission. 
 
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's ongoing care needs include ventilator support with tracheostomy care, 
neurologic monitoring, intravenous antibiotics, surveillance laboratory studies, wound debridement, tube 
feeding, and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on August 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the rendered services are not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the documentation supports that the ambulance services provided were medically reasonable and 
necessary. Our physician reviewer found in this case, the nursing staff reported the enrollee had a fall and 
seizure. The transporting technicians placed the enrollee on oxygen. The enrollee was noted to have dementia, 
but was alert and oriented at the time of transport. Review of the records support the medical necessity for 
emergency transport for the enrollee. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pay for the ambulance services provided on August 5, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from a network provider with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental office visit (D9430) provided June 15, 2020. 
 
You asked the Plan to pay for the dental office visit. You say that you never were provided any services at this 
visit because the dentist did not have the needed supplies. The Plan denied your request. The Plan says the type 
of visit billed by the dentist is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a dental 
office visit (D9430) provided June 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on July 1, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97530-GP-59 is not covered. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation does not support that this is a distinct procedure service apart from the 
previously billed code 97140. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for the physical therapy services rendered on July 1, 2019.
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 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 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 12, 
2020, and March 13, 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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80061: 
 
Lipid panel; This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct 
measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 
 
CPT 84450: 
 
Transferase; aspartate amino (AST) (SGOT) 
 
CPT 84460: 
 
Transferase; alanine amino (ALT) (SGPT) 
 
CPT 94618: 
 
Pulmonary stress testing (e.g., six-minute walk test), including measurement of heart rate, oximetry, and 
oxygen titration, when performed 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
records do not support the denied codes. The records do not support that these services were ordered or 
rendered. 
 
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 pay for laboratory services provided to the enrollee on March 12, 2020, and March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions and anesthesia services. 
 
You asked the Plan to pre-approve dental extractions and anesthesia services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental extractions and 
anesthesia services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Purewick external catheter system. 
 
You asked the Plan to pre-approve Purewick external catheter system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are 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 Purewick external catheter system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic unspecified urinary incontinence. Prior evaluations 
and treatments were not provided in the medical records. Clinical studies and guidelines have not demonstrated 
that the Purewick system is an effective treatment for urinary incontinence. Therefore, the enrollee does not 
meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick external catheter system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Purewick external catheter system.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete series of intraoral X-rays provided on July 15, 2020. 
 
You asked the Plan to pay for the complete series of intraoral X-rays. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that you have exhausted 
the benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide proof that the enrollee did in fact exhaust their 
benefit for intraoral X-rays in 2018. Without any sort of proof that the enrollee received these X-rays, we are 
unable to confirm that the benefit was in fact exhausted. Therefore, we decided that the Plan has to pay for the 
complete series of intraoral X-rays provided on July 15, 2020.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve atomoxetine 10mg capsules. 
 
You asked the Plan to pre-approve the atomoxetine capsules. You say that this medication is necessary. The 
Plan denied your request. The Plan says this oral drug cannot be covered by Medicare Part B. 
 
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 atomoxetine 10mg capsules.  
 
Benefits for the atomoxetine capsules may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog injections. 
 
You asked the Plan to pre-approve the Novolog. You say that this is necessary for treatment of type 2 diabetes. 
The Plan denied your request. The Plan says this self-injected drug is not covered by Medicare Part B. 
 
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 Novolog injections.  
 
Benefits for the Novolog may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal on 
tooth #20 and 22 (CPT Code D6750) and pontic - porcelain fused to high noble metal (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your handbook as a covered benefit; 
therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve 
retainer crown - porcelain fused to high noble metal on tooth #20 and 22 (CPT Code D6750) and pontic - 
porcelain fused to high noble metal (D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says most cases 
the care you receive from an out-of-network provider will not be covered. If you need medical care that 
Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this 
care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to 
seeking care.  
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required after January 9, 2021. Services three times per week are recommended in the 
provided medical records. This enrollee does not require the services on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 8, 2020 
to September 9, 2020.
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says coverage criteria was not met. 
 
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 the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or 
observation care) would span two midnights. 
 
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 September 8, 2020 to September 9, 
2020.
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 requested IRF care is medically necessary. The 
Plan denied your request. The Plan says the criteria for this level of care are not 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 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 was admitted with back pain and hypoxia due to unresolved pneumonia. 
He was found to have a T4 fracture on MRI. 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. 
 
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.