Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can 
safely receive the services you need in other settings, for example: a skilled nursing facility. 
 
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 review indicates that the complexity of your nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program.  There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on November 2, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on November 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
September 17, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 an emergency room visit. Based on your contract with the 
Plan, cost-sharing for emergency care is only waived if you are admitted into the hospital for the same 
condition within 24 hours.  
 
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 provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic (D6242) for tooth #19 and retainer crowns (D6750) for 
tooth #'s 18 and 20. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that it is believed it would be in 
your best long-term interest medically to receive implants versus dentures. The Plan denied your request. The 
Plan says that you are missing multiple teeth in the same arch. The Plan also says that a partial would 
adequately replace multiple missing teeth if the treatment meets criteria for a partial denture. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the pontic and 
retainer crowns when the services are medically necessary and reasonable. 
 
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 pontic and retainer crowns. Our 
reviewer says that the documentation provided meets the criteria for coverage for a replacement fixed bridge to 
replace missing tooth #19 with a pontic (D6242), using tooth #'s 18 and 20 as abutment retainers (D6750). Our 
physician reviewer found the current bridge is defective due to recurrent caries on the retainers. Our reviewer 
found that since the bridge has to be replaced to effectively treat the caries, new crowns would have to be 
placed on tooth #'s 18 and 20. Our physician reviewer also found that a new bridge is reasonable and necessary 
to maintain good masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic and retainer crowns have been met. Therefore, we decided that the 
Plan has to pre-approve a pontic (D6242) for tooth #19 and retainer crowns (D6750) for tooth #'s 18 and 20.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivacaine injection provided on May 12, 2021, billed 
with code S0020. 
 
You asked the Plan to pay for the drug injection as billed. You say that this claim should be paid in full. The 
Plan denied your request. The Plan says payment was approved for the injection codes; however, the use of 
S0020 is not appropriate for Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
Code S0020 has a status indicator of "I" in the Physician Fee Schedule. This means that the code is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the drug 
injection as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
bupivacaine injection provided on May 12, 2021, billed with code S0020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on February 25, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $50 towards the water pick and colonoscopy prep items. We decided that 
the Plan does not have to pay any amount in excess of $50 for the over-the-counter items.  
 
You asked the Plan to pay for the water pick and colonoscopy preparation items. You say that you would like 
reconsideration because you have an over-the-counter benefit that should cover these items. The Plan says that 
these items are not covered under your supplemental dental benefit. 
 We decided that the Plan has to pay $50 towards the over-the-counter items.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for over-the-counter (OTC) 
items, including non-prescription drugs. The Plan offers an additional benefit to cover $50 towards OTC items 
per quarter.  
 
We looked at your request, the file and rules. Based on this information we have decided that criteria for 
coverage of up to $50 for the OTC items have been met. Specifically, the Plan offers a $50 quarterly benefit for 
OTC items. The Plan has not supplied any evidence to indicate that the items at issue are not covered under this 
benefit. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
$50 towards the over-the-counter items.  
 
We also decided that the Plan does not have to pay any amount in excess of $50 for the over-the-counter 
items. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for over-the-counter (OTC) 
items, including non-prescription drugs. The Plan offers an additional benefit to cover $50 towards OTC items 
per quarter.  
 
We looked at your request, the file and rules. Based on this information we have decided that coverage criteria 
for the remaining balance for the OTC items have not been met. Specifically, the Plan offers an OTC benefit 
which covers up to $50 towards OTC items. The requested items exceed $50 so any remaining balance is not 
covered. Therefore, we decided that the Plan does not have to pay any amount in excess of $50 for the over-
the-counter items. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), and 
gingivectomy (D4212) for tooth # 15. 
 
You asked the Plan to pre-approve the dental services. You say that after the removal of the existing restoration 
and recurring decay, over 70% of the occlusal surface will be compromised. You also say that a full coverage 
crown is necessary to restore complete form and function. The Plan denied your request. The Plan says the 
crown and core build up for tooth # 15 are not medically necessary. The Plan also says gingivectomy 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the crown and core build up are not medically necessary. Our physician reviewer found the provided 
records and radiographs do not show a significant coronal breakdown due to caries or fracture requiring a 
crown restoration for tooth # 15. Therefore, the reviewer found that the requested crown and core build up are 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Specifically, the file does not show that 
tooth # 15 has significant breakdown that would warrant a crown. Additionally, gingivectomy is not among the 
services covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2740), core build up (D2950), and gingivectomy (D4212) for tooth # 15.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of an arterial catheter provided on September 30, 
2021, billed with code 36140. 
 
You asked the Plan to pay for the services as billed. You say that this claim should be paid as authorization was 
requested and obtained. The Plan denied your request. The Plan says it was found that authorization was 
obtained, and payment was made for most services on the claim. Of the services that are payable per the 
Outpatient Prospective Payment System (OPPS), all were paid aside from 36140 as it was not billed with an 
appropriate modifier. 
 
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, we have confirmed that code 36140 
is a column II code to column I code 93454. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for placement of an arterial catheter provided on September 30, 
2021, billed with code 36140.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on July 19, 2021. 
 
You asked the Plan to pay for the crown. You say that you bought a dental plan that included crowns. You also 
say that no one told you that you were dropped from the Plan or that you had to reinstate yearly. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also 
says that you did not contact the Plan prior to this date of service to verify 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 crown 
(D2740) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit (99214) rendered 
on September 14, 2021. 
 
You asked the Plan to reduce the copayment for an office visit. You say that the provider coded the service as a 
regular outpatient visit and not a post operative visit, therefore, having you be responsible for an outpatient 
office visit copayment when it should be covered with the surgery. The Plan denied your request. The Plan says 
you were charged the correct cost sharing amount. 
 
 
 
 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 $35 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse or 
physicians assistant or other non-physician health care professionals in a specialists office.  
 
You have been asked to pay $34.47, which is less than the $35 copayment for an office visit. An office visit 
falls within the physician/practitioner services, including doctor's office visits benefit category. The record 
shows that this specialist office visit was outside of the 90 day post operative time period. 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 reduce the copayment for a specialist office visit (99214) rendered on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has poor function and has been making 
progress with physical therapy. You state the enrollee is motivated and willing to work four (4) hours a day to 
regain mobility. You state that the enrollee is obese with end stage renal disease (ESRD). The Plan denied your 
request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 review indicates that 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 does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance 
imaging (MRI) of the heart. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is outside of the network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for magnetic resonance imaging (MRI) of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told that most 
insurance pays for these x-rays. You also say that you are in-network and that the welcome kit says x-rays are 
covered. The Plan denied your request. The Plan says this service is not covered by 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 
complete series of intraoral x-rays (D0210) provided on October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
enrollee could receive care in another setting and the Plan could review alternate settings if requested, such as 
skilled nursing facility, outpatient setting or home health 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical conditions are stable on outpatient medications with no active issues that require a physicians 
evaluation three or more times per week. The enrollee does require physical therapy and occupational therapy 
services, but the medical records provided do not support that the enrollee requires an intensive inpatient 
rehabilitation therapy program. Provided medical records do not support that the enrollee requires and can 
tolerate 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 IRF admission and services.