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

 
We decided that the Plan does not have to pre-approve surgical bone reshaping (D4260), adding bone on tooth 
#2 and 3 (D4263), and adding tissue materials on tooth #2 and 3 (D4265). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says surgical bone reshaping (D4260), adding bone (D4263), 
and adding tissue materials (D4265) are not covered by your dental 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. 
 
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 
surgical bone reshaping (D4260), adding bone on tooth #2 and 3 (D4263), and adding tissue materials on tooth 
#2 and 3 (D4265).
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  LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says you are receiving appropriate inpatient care at the current hospital 
and the LTACH would offer no additional services. 
 
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 that you do not require services at the LTACH that are not already available at the 
current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 a hip fracture after a fall. 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, in 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. 
 
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 pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you have been with this office for over 40 
years. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site 
in quadrant (D4263), guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) 
(D4267), and surgical removal of implant body (D6100) provided February 23, 2022. 
 
You asked the Plan to pay for the bone replacement graft, guided tissue regeneration, and surgical removal of 
an implant. You say that you were referred to this provider. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
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 bone 
replacement graft - retained natural tooth - first site in quadrant (D4263), guided tissue regeneration - 
nonresorbable barrier, per site (includes membrane removal) (D4267), and surgical removal of implant body 
(D6100) provided February 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
 
 You asked the Plan to pre-approve the SNF care. You say that you are not physically ready to be released from 
the current SNF you are in. You say you are asking to be moved to a different SNF due to lack of care. The 
Plan denied your request. The Plan says authorization denied because the SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the SNF care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found that you do not require further skilled 
nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further 
rehabilitation services at a lower level of care.  Although further rehabilitation services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. You do not have any parental medication such as complex wound care or 
nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical 
problems. Your physical function is at or near her baseline and she can receive services at a lower level of care.  
Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and the LTACH would offer no additional services. 
 
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 that the enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at an alternate 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 that while the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services that an IRF would provide. 
 
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 a comprehensive oral evaluation (D0150) and a panoramic x-
ray (D0330) provided on March 10, 2022. 
 
You asked the Plan to pay for an evaluation and a panoramic x-ray. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says your benefit for a comprehensive oral 
evaluation and a panoramic x-ray have already been exhausted. 
 
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 a comprehensive oral evaluation and a panoramic x-ray was exhausted on date of 
service August 14, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and a panoramic x-ray (D0330) provided on March 10, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the replacement of a tunneled catheter (36581) and fluoroscopic 
guidance (77001) provided on December 31, 2021. 
 
You asked the Plan to pay for the replacement of a tunneled catheter and fluoroscopic guidance. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
that these services are included in the global surgery package for CPT code 36558. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of other physicians are not included 
in the payment amount for a procedure with the appropriate indicator in Field 16 of the Medicare Physician Fee 
Schedule (MFSDB). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement of a tunneled catheter and fluoroscopic guidance have been met. Specifically, the 
documentation indicates that these services were not rendered by the physician who rendered the initial 
surgery. Payment for these services is not included in the global surgery package. Therefore, we decided that 
the Plan has to pay for the replacement of a tunneled catheter (36581) and fluoroscopic guidance (77001) 
provided on December 31, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that that the enrollee is a high fall risk and is only 
able to walk 150 feet with 3 rest breaks. You state that the physical and occupational therapy are recommended 
because the enrollee lives alone and is not safe to go home. The Plan denied your request. The Plan says 
authorization denied because the enrollee does not meet CMS criteria, and the enrollee's needs can be met at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the SNF care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found the enrollee has stabilized medically 
and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled 
therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a 
lower level of care.  Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. The enrollee does not have any parental medication, such as complex wound care or nutrition given via 
a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her 
physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a 
SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
one power seating system motor (E2310). 
 
You asked the Plan to pre-approve electronic connection. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the electronic connection 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-
approve electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve to replace all teeth and acrylic on cast metal framework 
(D5671). 
 
You asked the Plan to pre-approve the dental services. You say that you need this service to be able to chew 
food properly. The Plan denied your request. The Plan says to replace all teeth and acrylic on cast metal 
framework (D5671) is not covered by your routine dental 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. 
 
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 to 
replace all teeth and acrylic on cast metal framework (D5671).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an alveoloplasty (D7310) and the extraction of tooth #5 
and 6 (D7210), and to pay for a consultation provided on November 5, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. The Plan also 
says that a consultation (D9310) is not covered by the Plans dental 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. A 
consultation (D9310) is not covered under this benefit. Therefore, we decided that the Plan does not have to 
pay more for an alveoloplasty (D7310) and the extraction of tooth #5 and 6 (D7210), and to pay for a 
consultation provided on November 5, 2021.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 a stroke. 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, in 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. 
 
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 an extraction of tooth #30 (D7210) provided on January 14, 
2022, and extractions of tooth #8, 9, 10, 11, and 13 (D7210) provided on February 5, 2022. 
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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 requested item or service was exhausted on date of service January 14, 2022. 
Therefore, we decided that the Plan does not have to pay for an extraction of tooth #30 (D7210) provided on 
January 14, 2022, and extractions of tooth #8, 9, 10, 11, and 13 (D7210) provided on February 5, 2022.